California Nursing & Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure wound treatments ordered by a wound consultant were implemented in a timely manner for five of six residents reviewed for pressure injuries (PI - bed sore), Residents 1, 2, 3, 4, and 5. This failure resulted in the delay of the appropriate treatment as ordered by the wound consultant and contributed to the worsening of Residents 1 and 2's PI. In addition, this failure had the potential to contribute to the worsening of Residents 3, 4 and 5's PI.

Inspectors wroteBased on interview and record review, the facility failed to conduct and review planned quality improvement monitoring activities and audits to determine whether corrective actions were effective for the problems identified for pressure injuries (PI). This failure resulted in wound treatment orders recommended by the wound consultant (WMD) not being implemented in a timely manner, for five of six residents reviewed for PIs. (Cross refer F-686)

Inspectors wroteBased on observation, interview, and record review, the facility failed to immediately respond to a Wander Guard alarm (A bracelet that triggers an alarm when the resident attempts to exit the facility - elopement) for one of three residents reviewed (Resident 1). This failure resulted in Resident 1's elopement from the facility. Resident 1 experienced a fall outside of the facility and was transported to the General Acute Care Hospital (GACH) for evaluation and treatment.

Inspectors wroteBased on interview and record review, the facility failed to provide copies of medical records within two business days after receiving the written request from the resident representative, for one of two residents reviewed, Resident 1. This failure is a violation of Resident 1 and the resident's representative's rights.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the kitchen environment in a clean and sanitary condition when:1. The kitchen sink and underneath the preparation counter were found to have black residue, dark build up, and areas of flaking and rusty-brown discoloration.2. The underside and bottom portion of the kitchen sink were coated with stains and spots of scattered yellow and brown food debris. 3. The kitchen sink's white funnel-shaped drainpipe contained debris, rust, and old food residue. These failures had the potential to expose residents to contaminants and increased the risk of food-borne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to ensure its Payroll Based Journal (a mandated reporting system used by the Centers for Medicare & Medicaid Services (CMS) to collect auditable, employee-level staffing data from long-term care facilities) was submitted for the first fiscal year quarter. This deficient practice resulted in the facility's failure to provide required information regarding staffing levels necessary to ensure the provision of safe and comprehensive care for all residents in accordance with federal regulations.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary respiratory care and services in accordance with professional standards of practice for three of five sampled residents (Resident 17, 1, and 39) when:Resident 17's respiratory bag was mislabeled, and respiratory supplies were not labeled changed as ordered. Resident 1's nasal cannula (NC- a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) was not changed as ordered. Resident 39's respiratory supplies were unlabeled and kept in Resident 39's bedside for several days after the treatment was completed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored properly and securely when a medication cart (Medication Cart 3) was left unlocked and not under direct observation by authorized staff. This had the potential to allow unauthorized access to medications and supplies which could cause undetected misuse, diversion (distribution, abuse, or use of drugs for purposes not intended by the prescriber), and unsafe use of medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care was provided in a dignified manner for one of 17 sampled residents (Resident 12) when a Certified Nursing Assistant (CNA) 1 fed Resident 12 while standing and not at eye level. This failure had the potential to have a negative impact on Resident 12's psychosocial well-being during dining.

Inspectors wroteBased on interview and record review, the facility failed to ensure an informed consent (a process providing the resident and/or resident representative information regarding risks, benefits, and potential side effects [unintended or adverse reactions caused by a medication] of treatment before agreement for treatment) was obtained prior to the administration of an increased dose of a psychotropic (medications affecting brain activities associated with mental processes and behaviors) medication for one of five sampled residents (Resident 16) reviewed for unnecessary medications. This failure had the potential for residents and/or resident representatives not fully informed regarding medication risks, benefits, and potential side effects before the resident received an increased dose of a psychotropic medication.

Inspectors wroteBased on interview and record review, the facility failed to ensure timely completion of the comprehensive admission Minimum Data Set ([MDS] - a federally mandated resident assessment tool) assessments for one of 17 sampled residents (Resident 76). This deficient practice had the potential to delay the care planning process to meet Resident 76's comprehensive and individualized care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary nail care services and personal hygiene for one of two sampled residents (Resident 97) by failing to ensure Resident 97's fingernails were cleaned and trimmed. This failure resulted in Resident 97 having overgrown and untrimmed fingernails, which placed Resident 97 at risk for discomfort, impaired hygiene, skin breakdown and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure needed treatment and services were provided to maintain range of motion (ROM- full movement potential of a joint) for one of three sampled residents (Resident 4) when Resident 4's Restorative Nursing Program (a nursing-driven service in long-term care settings that helps residents maintain or improve their functional abilities to their highest possible level) orders were not followed and in accordance with Resident 4's plan of care. These failures had the potential to cause further decline in functional mobility, ROM, and quality of life for Resident 4.

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate accountability of controlled substances (CS - medications with high potential for abuse and addiction) for two of six randomly selected residents (Residents 45 and 51) who were reviewed for controlled substance accountability when:Resident 45's Tramadol (an opioid medication used to treat moderate to moderately severe pain) Individual Narcotic Record (inventory records used to document receipt, use, and count of controlled substances [medications with potential for abuse and dependence]) did not match the Medication Administration Record ([MAR] a daily documentation record used by a licensed nurse to document medications and treatments given to a resident). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to adequately monitor one of 17 sampled residents (Resident 34) for side effects (secondary, often predictable, unintended effects of a medication that can be beneficial, neutral, or harmful) and adverse drug reactions (strictly unintended, harmful, and unexpected reaction of a medication, usually requiring intervention) for the use an anticoagulant (medication that thins the blood to prevent blood clots) medication per facility's policy. This failure had the potential to result in adverse outcomes, including bleeding complications, bruising, hemorrhage, hospitalization, or other medication related complications associated with anticoagulant use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered in accordance with physician orders when a medication error rate of 8% was identified, with two medication errors out of 25 medication administration opportunities, during medication administration observations for one of four residents observed (Resident 39). These failures included the administration of an incorrect dose and an incorrect dosage form of medications, which had the potential to compromise the resident's medication therapy and safety.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 81) reviewed for unnecessary medications was free from a significant medication error when, Resident 81 did not receive phenobarbital (a controlled substance used to control seizures [a sudden, uncontrolled electrical disturbance in the brain that may cause involuntary jerking movements, staring spells, and/or loss of consciousness] by stabilizing electrical activity in the brain) as ordered by the physician for five consecutive days. The facility failed to ensure the physician was notified of the missed doses and failed to follow-up on the status of the medication with the facility's contracted pharmacy. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control and prevention measures when:1. The sharps container (a puncture-resistant, leak-proof receptacle designed for the safe disposal of medical sharps to prevent injury and infection) on one of three medication carts (Medication Cart 2) was filled beyond the fill line indicator.2. The Certified Nurse Assistant (CNA) 1 failed to follow the facility's policy for Enhanced Barrier Precautions ([EBP] - an infection control prevention designed to reduce the transmission of multi-drug-resistant organisms (MDROs) in healthcare settings, particularly nursing homes) when CNA 1 did not wear a gown while providing incontinent care to Resident 60. These failures had the potential for increased risk of infection which can compromise the health and wellbeing of residents, staff, and visitors.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of five sampled residents (Residents 17 and 52) reviewed for immunizations, were offered the COVID-19 (contagious respiratory illness caused by the SARS-CoV-2 virus) vaccine and failed to maintain documentation of vaccine education, refusals, or acceptance. These failures had the potential for Residents 17 and 52 to be unprotected against COVID-19, increased the risk of serious illness, delayed identification of vaccine status, and missed opportunities to prevent the spread of infection within the facility.

Inspectors wroteBased on interview and record review the facility failed to administer the resident's morning medications and notify the doctor (Dr) on February 20, 2026, for one of three residents reviewed (Resident 1). This failure had the potential for Resident 1 to experience adverse effects from not receiving their morning medications as ordered.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper infection control precautions were implemented for one of two residents (Resident 1), when a staff member was observed returning an unused dinner tray from a COVID (Corona virus - a contagious respiratory disease) positive residents isolation room (A room that separates residents from others, while receiving specialized medical treatment) to the meal cart which stored trays that were being served to other residents. This failure had the potential to cross contaminate clean resident dinner trays and spread COVID infection to uninfected residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a gastrostomy tube (g-tube, a tube inserted through the abdomen into the stomach, to deliver fluids and nutrition) stoma (opening) dressing change daily, for one of three residents reviewed (Resident 2). This failure had the potential to lead to skin breakdown or infection at/or around the stoma site.

Inspectors wroteBased on interview and record review, the facility failed to accurately monitor and document total fluid intake via gastrostomy tube (g-tube, tube inserted through the abdomen, into the stomach to administer medications, nutrition and hydration) and the output (I &O) per physician orders, for two out of three residents (Residents 1 and 2). This failure had the potential to result in resident dehydration leading to other health complications such as decreased urine output, dizziness, rapid heart rate, and altered mental status.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide wound treatment in accordance with the physician order for one of three sampled residents (Resident 1). This failure had the potential to delay wound healing for Resident 1.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement smoking precaution, by not providing a smoking apron (worn while smoking to help decrease incidents of burning self), to one of four residents (Resident 1) while smoking cigarette at the facility patio. This failure had the potential for Resident 1 to sustain burn injuries while smoking a cigarette.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a comprehensive systematic approach to ensure effective monitoring to maintain acceptable parameters of nutritional status for 5 of 5 sampled Residents (23, 43, 51, 58, and 673) when: 1. Resident 23 experienced a severe unplanned weight loss of 16 lbs. (pounds- a measurement of weight), 8.04% from the weights obtained on 11/5/24 to 2/26/25. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a Registered Dietitian (RD) carried out the functions of the registered dietitian when: 1. Timely monitoring of nutrition interventions was not conducted to meet the needs of 5 sampled residents, (23, 43, 51, 58 and 673) who experienced severe unintentional weight losses greater than 7.5% in three months; 2. The Diet manual was not updated, and facility menus were not followed; and 3. Unsanitary and unsafe food practices were conducted in the kitchen. These failures placed vulnerable residents at risk to poor improper practices that had the potential to further weaken and compromise their nutrition and health status based on their medical diagnoses. The facility census was 72.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food safety and sanitation practices were maintained in the kitchen according to standards of practice and facility policy when: 1. The ice machine was not properly maintained and cleaned per manufacturer guidelines; 2. The dish machine sanitizer solution was outside of the correct chemical range and tested 300- 400 ppm (parts per million- a unit of measurement); 3. Kitchen staff did not wear beard nets while working in the kitchen; 4. Dishes and three (3) large metal pans with food debris and dripping water on them were stacked on top of each other in a drawer; and 5. Kitchen staff were using cloth oven mitts that were wet, soiled, and had food build-up/residue on them. [...]

Inspectors wroteBased on interview and record review, the facility failed to have a written Quality Assurance Performance Improvement (QAPI - a systematic, interdisciplinary, comprehensive, and data-driven approach to maintain and improve safety, quality of care, and quality of life of the residents) plan in place to address the facility's systemic process issues related to weight loss, kitchen and nutrition services, and broken call light systems. These failures resulted in multiple residents to not receive appropriate care and treatment for weight loss and delayed response to residents' call lights. In addition, these failures had the potential for other residents at risk to not achieve their highest physical, mental, psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure essential food and nutrition services equipment, such as the reach in freezer, and ice machine were maintained in safe operating condition. These failures had the potential to impact the ability of dietary staff to prepare, store, and serve food in a safe and sanitary manner. Resident census was 72 at time of survey.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light system (a communication system that allow the residents to call for staff assistance) was fully functional when: 1. The call light system panel did not have an audible sound; and 2. Resident 23 did not have a call light button installed, available, and within reach. These failures had the potential for Resident 23 and the residents in the facility not to receive assistance from the staff in a timely manner.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure provision of pharmacy services met the needs of the residents when: 1. An emergency supply kit (E-kit, a sealed container with various medications for use in emergencies) containing controlled substance (CS, those with high potential for abuse and addiction) medications was stored opened and unsealed; 2. Residents 17 and 50 were missing documentation for the administration of CS medications. The CS medications were signed out of the Individual Narcotic Record (count sheet, an inventory sheet that keeps record of the usage of CS medications) but not documented on the Medication Administration Records (MAR) to indicate they were administered to the residents; Additionally for Resident 17 the CS medications were documented on the MAR but not signed out of the count sheet; and 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure the kitchen staff in the food and nutrition services department were trained according to standards of practice for food safety, sanitation, and facility policy when: 1. A [NAME] did not know how to use the chlorine test strips to test the sanitizer in the dish machine. 2. A Dietary Aide did not know how to calibrate a food thermometer. These failures in staff competency resulted in exposing 72 residents who consume food from the kitchen to practices associated with food borne illness as well as bacterial and chemical cross contamination and had the potential to cause illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the food was served at an acceptable temperature and palatability taste to the residents, according to the facility policy. This failure had the potential to affect meal and food intake which could impair the nutrition status of the 74 residents who consumed food from the kitchen. Cross Reference F800, F801, F803 During a review of the facility's Winter Menu, Week 4, the Tuesday 2/25/25 lunch meal for the Regular diet included 3oz (ounces) of herb crusted beef roast, 1/2 oz brown gravy, ½ cup mashed potatoes, ½ cup zesty spinach, parsley sprig garnish, 1 slice of garlic bread, and 1 Sq. (square) triple fruit crisp. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. The laundry room door was closed and staff were observed passing through the clean area of the laundry from the hallway; 2. Nursing staff failed to properly clean and disinfect shared blood pressure (BP-pressure of blood in blood vessels) cuffs and stethoscopes for Residents 475 and 58, according to the disposable Sani-Cloth disposable wipe manufacturer's specified contact time (the time the resident equipment was to be in contact with the disposable wipes to kill micro-organisms). In addition, the facility failed to properly clean and disinfect the shared stethoscope after use according to facility's policy; and 3. The lunch meal trays for Residents 17 and 23 were placed in the residents' room next to unsanitary bodily equipment. [...]

Inspectors wroteBased on interview and record review, the facility failed, for one of one resident reviewed (Resident 23), to ensure Resident 23 was appointed a resident representative (RR- someone who can act on behalf of a resident, typically a family member, guardian, or someone with legal authority, to make decisions regarding the resident's care and rights). This failure had resulted in Resident 23 not having a resident representative to exercise their rights or delegate Resident 23's medical decisions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to exercise reasonable care for the protection of resident's property from theft and loss for one of two residents reviewed for personal property (Resident 21). This failure resulted in Resident 21's violation of resident's rights of having a safe environment.

Inspectors wroteBased on interview and record review, the facility failed, for one of one resident reviewed (Resident 23), to ensure a follow-up with the local authority for the completion of a Level II Preadmission Screening and Resident Review (PASARR- a federally mandated process ensuring individuals with mental illness, intellectual/developmental disabilities, or related conditions receive appropriate placement and services in Medicaid-certified nursing facilities) was performed. This failure had the potential for Resident 23 to not receive the appropriate care according to his mental and behavioral needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure for one of two residents reviewed for care planning a care plan was initiated for toe nail fungus (Resident 43). This failure had the potential to result in ineffective treatment of foot care and cause pain or discomfort to resident 43.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services provided met professional standards of practice for two of 72 residents (Residents 57 and 58) reviewed when: 1. For Resident 57, one Albuterol Sulfate inhaler (medication used to treat breathing problems caused by lung disease) was observed on top of the resident's nightstand: and 2. For Resident 58, the facility did not clarify a physician's order for Vitamin D3 (a type of Vitamin supplement). These failures had the potential for Resident 57 to receive the Albuterol Sulfate inhaler without a physician's order, and for Resident 58 to receive a wrong dose for the Vitamin D3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure for one of 18 residents reviewed (Resident 224), multiple dry scabs located on bilateral (both) forearms was referred to the physician for treatment orders. This failure had the potential to result in Resident 224's skin condition to persist without prompt intervention thereby causing a possible further decline in health condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe smoking practices were observed and implemented for one of eight residents reviewed for smoking (Resident 12), when Resident 12 had cigarettes and lighter in his possession. This failure had the potential to result in accidents or injuries to the facility residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed, for one of one resident reviewed (Resident 23), to ensure bowel and bladder assessment and evaluation was performed for ascheduled toileting program. This failure resulted in no bladder training program for Resident 23 which had the potential to lead to further decline of bladder function.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care and treatment for one resident reviewed for oxygen administration (Resident 43), when the physician's order for oxygen administration was not followed. This failure had the potential to result in ineffective oxygen therapy, respiratory distress, and decline in the resident's health condition.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities during the monthly Medication Regimen Review (MRR) for one of six randomly selected residents (Resident 58) when the facility did not clarify the physician's order for Vitamin D3 (a type of Vitamin supplement). This failure had the potential for Resident 58 to receive a wrong dose of Vitamin D3.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the therapeutic menu was followed for two residents, a sampled resident 66, and unsampled resident 17, on renal diets (a diet to protect the health of the kidneys). These failures led to the two residents receiving foods that did not meet their nutritional needs and may have further compromised their health status. The facility census was 72.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their policy and procedure regarding food brought in from the outside, when one resident (Resident 66), who had a diagnosis of diabetes (chronic condition characterized by high blood sugar), had chocolate candies inside of his nightstand drawer that were brought in from the outside. This failure had the potential for Resident 66 to be non-compliant with the prescribed diet leading to high blood sugar.

Inspectors wroteBased on observations, interviews, and document reviews, the facility failed to ensure the physician's progress notes in the medical records were accurately completed for a sampled resident (Resident 673) and unsampled resident (Resident 3) with significant weight loss for the past one month. This failure had the potential to negatively impact health and nutrition status and lead to further decline of the two residents with significant weight loss. The facility census was 69. According to the April 10, 2010, Proceedings of the SIGCHI Conference on Human Factors in Computing Systems article Physician-Driven Management of Patient Progress Notes in an Intensive Care Unit; .A patient progress note is a clinical document, written by a .physician, describing a patient's status and the physician's assessments and care plan for the patient. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that bedrooms measured at least 80 square feet per resident, in bedrooms occupied by multiple residents (Rooms 3, 17, 20, and 33).

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident environment was free of accident hazards when one of 74 residents had a shotgun, two airsoft guns, and a chainsaw in his room (Resident 1). This failure resulted in Resident 1 having access to his shotgun, airsoft guns, and chainsaw, and could have resulted in mental anguish for the other residents in the facility, accidents or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility's policy and procedures were followed, for two of three sampled residents, Residents 1 and 2, who were identified as at risk for elopement (when a resident leaves a healthcare facility without permission or when they are unable to make safe decisions on their own), when: 1. The facility did not provide supervision for Resident 1 who had multiple prior attempts to elope; and 2. The facility did not ensure there was a system in place to monitor placement and functionality of the WanderGuard (bracelet worn by the resident that triggers alarms on doors to alert staff if a resident leaves a safe area) when Resident 2 was observed not wearing a WanderGuard bracelet as ordered by the physician. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure for two of three residents, Residents 1 and 2, the plan of care was reviewed and updated after Residents 1 and 2 attempted to elope (when a patient leaves a healthcare facility without supervision or detection while they are unable to protect themselves) from the facility. This failure resulted in Resident 1 eloping from the facility on November 18, 2024, and had the potential to result in Resident 2 eloping from the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect resident rights for dignity and respect for two of six sampled residents (Residents 1 and 2) when both residents were addressed in a disrespectful manner by a Certified Nurse Aide (CNA) 4. This failure had the potential to cause psychosocial harm and emotional distress to Resident 1 and Resident 2.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the personal privacy of one of six sampled residents (Resident 4) when a visitor unknown to the resident was allowed into the resident's room. This failure caused emotional distress to Resident 4 and put the resident's safety at risk.

Inspectors wroteBased on interview and record review, the facility failed to ensure an alleged abuse involving two of six sampled residents reviewed (Residents 1 and 2) were reported to the California Department of Public Health (CDPH) immediately or within two hours of the facility being aware of the alleged abuse. This failure had the potential to result in a delayed investigation of the alleged abuse causing a delay in implementation of corrective actions which placed the residents at risk for further abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 3) was supervised and interventions were put in placed to prevent elopement (leaving the facility without the staff's knowledge). This failure resulted in Resident 1 eloping from the facility and had the potential to cause injury and harm to the resident.

Inspectors wroteBased on interview and record review, the facility failed to promote care that maintained the dignity and respect for one resident (Resident 1), when he was told by facility staff to stop turning his f****** (expletive) call light on if he wanted to be left alone. This failure had the potential to affect Resident 1's psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three residents reviewed (Resident 4) was assessed, monitored, and supervised to prevent elopement (leaving the facility without permission). This failure resulted in Resident 4 eloping from the facility and had the potential to cause injury and harm to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain temperatures between 71 to 81 degrees Fahrenheit (F) when resident room temperatures in two of eight sampled resident rooms, reached 82.9 degrees F and one of one sampled common area room (activity room) was 81.5 degrees F. This deficient practice resulted in discomfort for two of seven sampled residents (Residents 1 and 2), and potential adverse health effects for residents, staff and visitors including dehydration (loss of body fluids), heat stress (a series of conditions where the body is under stress from overheating), and heat stroke (when the body can no longer control its temperature).

Inspectors wroteBased on interview and record review, the facility failed to provide the resident ' s representative with requested financial documents within 48 hrs. after request was made, for one of three sampled residents (Resident 1). This failure has the potential to result in missed payment which could negatively impact the resident or the resident's representative's financial standing.

Inspectors wroteBased on interview and record review the facility failed to notify the physician for one of three sampled residents (Resident 1) when: 1. The physician was not notified regarding Resident 1's change in treatment plan after the resident refused emergency room evaluation after experiencing a fall; and 2. The physician was not notified until the following day after Resident 1 sustained a fall. This failure had the potential to jeopardize the health and safety of Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure a safe environment according to their fall management policy and procedure for one of three sampled residents when: 1. The facility did not conduct an Inter-disciplinary Team (IDT) meeting to determine the root cause of Resident 1's fall on February 24, 2024; and 2. The facility did not accurately assess Resident 1's fall risk after the resident sustained a fall on March 20, 2024. This failure had the potential to result in further falls and harm for Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed, for one of four sampled residents reviewed (Resident 1) to ensure two bottles of oral nutritional supplements (health supplement) had a physician's order and were not stored by the bedside. This failure had the potential to result in incorrect self-administration of medication by Resident 1 and unauthorized access of other residents and staff to the medication.

Inspectors wroteBased on interview and record review the facility failed to provide bed hold notification for one of three sampled residents (Resident 1) prior to discharge to acute care. This failure had the potential result in Resident 1 not being able to return to the facility after discharged from acute care.

Inspectors wroteBased on interview and record review the facility failed to report an allegation of abuse for one of three sampled residents (Resident 3) to the California Department of Public Health (CDPH), immediately but not later than 2 hours after the allegation was made. The facility was made aware of the allegation on January 4, 2024. This failure had the potential to result in a delay of investigation and reporting of further allegations of abuse.

Inspectors wroteBased on observation, interview and record review the facility failed to follow their policy and procedure when staff did not wear face masks during a covid-19 (coronavirus- infectious agent) outbreak in the facility. This failure had the potential to infect staff and residents with an infectious agent (COVID-19).

Inspectors wroteBased on interview and record review, the facility failed to accurately re-imburse the resident ' s funds, for one of four residents reviewed (Resident 1). When Resident 1 ' s social security (SS) payment was inadvertently deposited into another resident ' s account and an audit was not conducted to verify the exact amount of Resident 1 ' s re-imbursement. This failure had the potential for a misappropriation of funds to occur.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was supervised and interventions were put in place to prevent elopement (leaving the facility without the staff's knowledge). This failure resulted in Resident 1 eloping from the facility and had the potential to cause injury and harm to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was supervised and interventions were put in place to prevent elopement (leaving the facility without the staff's knowledge). This failure resulted in Resident 1 eloping from the facility and had the potential to cause injury and harm to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety when: a. Multiple food items were stored beyond their use by dates, readily available for use; and b. The ice machine was dirty. These failures had the potential to cause foodborne illnesses in medically vulnerable resident population who consumed food in the facility. The facility census was 69.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the licensed nurses documented by signing their names in the eMAR (electronic Medication Administration Record) after administering the controlled medications (such as narcotics - medications that dull the senses, relieve pain, treat seizures but in excess doses cause stupors, coma, or convulsions) to residents for pain and seizures for four of four residents reviewed (Residents 2, 34, 63, and 69) on multiple shifts and days in March and April 2022. This failure increased the potential for drug diversion (use of medication not intended by the prescriber).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Consultant Pharmacist (CP) identified irregularities in the use of medications for 12 of 12 residents reviewed (Resident 2, 10, 11, 19, 35, 40, 41, 48, 60, 63, 69, and 121) when: 1. The licensed nurses administered Vitamin D following duplicated physician orders to Resident 2; and 2. There was no documented evidence medications were administered to the residents for March 2022, and April 2022. In addition, the CP was not able to review the eMAR's (electronic Medication Administration Records) and did not make recommendations regarding nursing staff not documenting the medication administration on multiple shifts on multiple days. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure, for 12 of 12 residents reviewed for unnecessary medications (Resident 2, 10, 11, 19, 35, 40, 41, 48, 60, 63, 69, and 121) there was no documented evidence the use of the medications were monitored for March 2022, and April 2022. This failure had the potential to result in the residents' medications being used and not evaluated for possible identification of medication-related problems and complications the residents may have.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the planned menu was followed for 21 of 21 residents with a physician ordered CCHO (Consistent Carbohydrate) diet (a diet used in the treatment for diabetes), when the residents received a full slice of lemon snow bar for dessert, instead of half a slice per the planned menu. Additionally, one resident on a low fat/low cholesterol diet received a full slice of the lemon snow bar for dessert instead of half a cup of fresh fruit. This failure had the potential to result in increased blood glucose levels for residents with a CCHO diet, and increased caloric intake for the resident on a low fat/low cholesterol diet.

Inspectors wroteBased on interview and record review the facility failed to provide a written copy of the bed hold policy for transfers to the hospital for three of three residents reviewed for hospitalizations(Residents 60, 69, and 11). This failure had the potential for Resident 60, Resident 69 and Resident 11 to be uninformed regarding their right to request a bed hold while they were hospitalized .

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Resident 14 was up in a geriatric chair (geri-chair-a large, padded chair that is designed to help with limited mobility) daily as ordered by the physician. This failure could potentially result in a decline in Resident 14's activities of daily living (ADLs).

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their policy and procedure for safe smoking practices for one of one resident reviewed for smoking (Resident 35). This failure had the potential for increased risk for smoking related injuries for Resident 35.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that there was a physician's order for the continued use of an indwelling Foley catheter (a flexible tube inserted into the bladder to provide continuous urinary drainage) for one of two residents reviewed for an indwelling catheter (Resident 37). This failure had a potential to result in unnecessary catheterization of Resident 37.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow current acceptable principles to label and store medications and biologicals (used to treat, prevent, and diagnose diseases and medical conditions) when: 1. A discontinued medication was stored in the medication cart, readily available to use. This failure increased the risk for the licensed nurses to administer discontinued medication to the residents which could result in medication and treatment errors; 2. An insulin pen was in use with no open date. This failure had the potential for licensed staff to administer the insulin to a resident past its expiration date; and 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that bedrooms measured at least 80 square feet per resident, in bedrooms occupied by multiple residents (Rooms 3, 17, 20, and 33).