Channel Islands Post Acute

Inspectors wroteBased on record review, interview, and facility Policy and Procedure (P/P) the facility failed to ensure care plan interventions were updated following score increase, multiple subsequent falls for one and three resident (Resident 1). This facility failure resulted with resident having repeated preventable falls. During a concurrent interview on 4/12/26 at 11:30 a.m., the Minimum Data Set (MDS) coordinator confirmed that Resident 1 experienced three previous falls (on 10/17/25, 11/27/25, and 12/11/25) prior to a fourth fall on 3/31/26. This most recent incident resulted in a left periprosthetic femoral fracture (a break in the thigh bone adjacent to a hip prosthesis). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide sufficient staffing to provide care for the residents. This failure has the potential to affect the resident quality of care. A review of All Facilities Letter (AFL) dated 3/17/21, the AFL summary indicated In accordance with HSC sections 1276.5 and 1276.65, and W & I section 14126.022, this notice provides updated guidelines for facility requirements during state audits for compliance with the 3.5 DHPPD staffing requirements, of which a minimum of 2.4 DHPPD shall be performed by certified nurse assistants (CNAs). During a concurrent interview and record review on 8/19/25 at 4:30 p.m with the Director of Nursing (DON) the Census and Direct Care Service Hours Per Patient Day (DHPPD - a staffing metric for skilled nursing facilities (SNFs), for the dates of 7/24/25 - 8/6/25 was reviewed. [...]

Inspectors wroteBased on interview, and record review, the facility staff failed to ensure a significant change in condition for one of three sampled resident (Resident 1) was communicated to ensure prompt consult with the resident's physician when the Certified Nursing Assistant (CNA 1) noticed Resident 1 was becoming more tired and needed to be assisted with meals. This failure resulted in delay in treamnet for the resident. Review of Resident I clinical records indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses that included Alcohol cirrhosis (chronic liver failure) of liver with ascites (abnormal build up of fluid in the abdomen), hepatic encephalopathy (altered level of consciousness as a result of liver failure), pleural effusion (accumulation of excessive fluid in the space that surrounds each lung), heart failure, generalized swelling. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to have one of three sampled residents (Resident 1) the right to retain and use personal possessions when a denture delivered to the resident was never documented nor found. This facility failure has the potential to create negative consequences whereby the resident feels not treated with respect.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its facility policies when: 1) Four expired drugs were available to be administered to residents 2) One medication was not administered as ordered by the physician for 1 of 31 sampled residents (Resident 43) 3) A consistent medication re-ordering process was not implemented 4) Multiple resident medications were not available timely and consistently 5) Two bags of sodium chloride (a salty solution given for dehydration) were inside the intravenous emergency kit (IV e-kit: a container with all the components needed to inject fluids, nutrients, and medications directly in the veins) but were not listed on the contents label. These failures had the potential to result in negative resident outcomes, jeopardizing the quality of safety of resident care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy and procedure with Self-Administration of Medications for 1 of 31 sampled residents (Resident 39) found with multiple self-medications by the bedside. This failure has the potential to result in medication error.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide safe, clean and home-like environment to 2 of 31 sampled residents (Residents 73 and 127) when: 1. Resident 127's room was found with loose floor tiles partially lifted creating a raised gap. 2. Resident 73's room was found with cobwebs in the ceiling, scratches on the wall by the headboard, and missing wall tiles in bathroom. These failures have the potential to affect residents' well-being.

Inspectors wroteBased on observations, interviews and record review, the facility failed to accurately assess the status of residents to reflect with the Minimum Data Set (MDS - an assessment tool used to assess residents in nursing homes) for 3 of 3 unsampled residents (Resident 95, Resident 119 and Resident 130) when: 1. Resident 95 had an inaccurate assessment for injection (administering a substance using a needle and a syringe) use. 2. Resident 119 had an inaccurate assessment for anticoagulants (a medication that prevents blood clots from forming) use. 3. Resident 130 had an inaccurate assessment for tobacco use. These failures have the have the potential to prevent relevant care areas about the resident's status not being met.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a PASSR Level I (preliminary assessment for individuals seeking admission to a Medicaid-certified nursing facility to determine if they might have a serious mental illness (SMI), intellectual disability (ID), or a related condition (RC)) and Level II (a comprehensive assessment conducted on individuals identified in the Level 1 screening as potentially having a mental illness or intellectual disability ID) were conducted for 2 of 31 sampled residents (Resident 10 and Resident 92). These failures had the potential to compromise resident care planning of the actual problems not to be addressed.

Inspectors wroteBased on observation, interview and review of the facility's policy and procedure (P&P), the facility failed to store medications in the storage refrigerator under proper temperature controls. This failure has the potential to result in a loss of effectiveness in medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the dietary staff labelled and dated food storage stored. These deficient practices placed the residents at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages).

Inspectors wroteBased on interviews and records review, the facility failed to provide sufficient discharge planning for one of three sampled residents (Resident 1) when the facility did not ensure needed home health services were in place prior to Resident 1's discharge. This failure resulted in Resident 1 not being provided needed home services.

Inspectors wroteBased on record review and interview, the facility failed to ensure that one of the three sampled residents (Resident 1) was treated with respect and dignity when Resident 1's personal belongings were relocated to another room. This failure created a situation whereby resident1's right to retain and use personal possessions was prevented.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person focused care plan for one of the three sampled residents(Resident 1) when activities of daily living (ADL) self-care deficit nursing needs were not addressed. This failure placed Resident 1 at risk of not having care needs met secondary to no plan in place.

Inspectors wroteBased on record review and interview, the facility failed to ensure that one (Resident 1) of the three sampled residents received services (bathroom help) to maintain grooming and personal hygiene. Resident 1 was not assisted to the availability of a urinal ( bedside portable plastic receptable for male urine) for over an hour after requesting assistance with toileting and ended up wetting/urinating on self. This failure had the potential to weaken resident 1 ' s bladder muscles and could raise risk of moisture associated skin damage (MASD) if exposed to various body wastes and fluids over an extended period of time.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure residents with a positive Level I Preadmission Screening and Resident Review (PASRR) received a Level II evaluation. Specifically, after the cases for 2 (Resident #80 and Resident #5) of 5 residents reviewed for PASRR requirements were closed, the facility failed to resubmit Level I PASRRs to reopen the cases as directed by the Department of Health Care Services to ensure Level II evaluations were completed. Findings Included: A facility policy titled, PASRR, reviewed in 01/2024, revealed, It is the policy of this facility to ensure that each resident is properly screened using the PASRR specified by the State. 1. An admission Record revealed the facility originally admitted Resident #80 on 01/24/2012 and readmitted the resident on 12/24/2022. [...]

Inspectors wroteBased on observation, interview, record review, and facility document and policy review, the facility failed to ensure the residents' environment remained as free of accident hazards as possible when unsecured medications were observed in residents' rooms without staff present. This deficient practice affected 1 (Resident #33) of 3 sampled residents reviewed for accidents and 1 (Resident #65) of 2 sampled residents reviewed for choices.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement one of two sampled residents (Resident 1) care plans indicating, Resident 1's bed should have bedside rails. The facility's failure placed Resident 1 at risk of falling out of bed and needing assistance with mobility and repositioning.

Inspectors wroteBased on record review, and interview, the facility failed to ensure one of 22 sampled residents (Resident 5) received an accurate admission Minimum Data Set (MDS, a standardized tool for care management) that is reflective of Resident 5's status. This facility failure had the potential to affect Resident 5's care needs and outcome.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure policy and procedure was followed when: 1. No bottom sheet covered specialized mattress while one of twenty-two sampled residents (Resident 54) was lying in bed. This failure had the potential to cause skin breakdown and discomfort. 2. Staff did not dispose of thin single layer plastic bag containing brief with feces before holding the handles of a wheelchair to transport of one of twenty-two sampled residents (Resident 54) from the resident room into the common hallway. This failure had the potential to cause cross contamination of facility surfaces.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the menu as planned when: 1. Cranberry-ginger citrus sauce was placed on top of turkey for one of 22 sampled residents (Resident 54) on a CCHO diet (controlled carbohydrate/diabetic diet), instead of gravy as planned. 2. The portion size for one pureed item did not match the menu for one of 22 sampled residents (Resident 94). This facility failure had the potential to not meet the resident's nutritional needs per the planned menu as approved by the facility's Registered Dietitian.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a potentially hazardous food that was leftover from a dinner meal was cooled down to ensure food safety. This facility failure had the potential to cause foodborne illness.