Chinese Hospital D/P SNF

Inspectors wroteBased on interview and record review, the facility failed to ensure three of six sampled residents (Residents 26, 14, and 15) were free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) when:1. For Resident 26, there was no specific target behavior monitoring for the use of Lorazepam (medication used to treat anxiety) and2. For Residents 14 and 15, there was no diagnosis and/or specific condition for the use of antipsychotic medication. These deficient practices had the potential for residents to receive unnecessary psychotropic medication, be exposed to adverse health consequences from the medication, which could negatively impact the resident's mental, physical, and psychosocial well-being.1. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to develop care plans for Residents 1, 14, 15, and 26, four residents out of a total sample of 8 residents. These were the areas the facility failed to care plan:Resident 15- antipsychotic medicationResident 1- anti-anxiety medication Resident 26- anti-anxiety medicationResident 14- bed railsThese failures had the potential to negatively impact these residents' health and safety.1. A concurrent interview and review of Resident 15's medical records was conducted on 2/24/26 at 1:59 PM with the Director of Staff Development (DSD). Review of Resident 15's medical records titled Order Summary Report, for February 2026, indicated Resident 15 had a physician order for .Paliperidone Palmitate. for schizoaffective (once a month injection to be administered at a clinic). [...]

Inspectors wroteBased on interview and record review, the facility failed to report three allegations of abuse within the mandated time frame to California Department of Public Health (CDPH), the Ombudsman (advocates for residents in nursing homes), and local law enforcement for one of one sampled resident (Resident 34). In addition, the facility failed to report the result of its investigation to CDPH within five working days. This failure to follow mandated reporting timeframes had the potential to delay investigation and implementation of protective measures for all residents of the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to send notification to Ombudsman for one of two residents (Resident 24) when Resident 24 was discharged from the facility against medical advice (AMA). This failure had the potential for resident not having the right to appeal when necessary. Resident 24 was admitted on [DATE] with diagnoses including metabolic encephalopathy (brain dysfunction caused by underlying condition), anemia (when you have low levels of healthy red blood cells to carry oxygen throughout your body) and congestive heart failure (a chronic condition where the heart cannot pump blood efficiently, causing fluid buildup, fatigue, and shortness of breath). Review of facility document titled, Notice of Transfer or Discharge, dated 12/16/25, indicated, Resident 24 was discharged AMA on 12/16/25. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain a physician's (MD) order and develop a comprehensive care plan for the use of external catheter for one of one sampled resident (Resident 26). These deficient practices had the potential for resident not to receive appropriate treatment and services. Resident 26 was admitted on [DATE] with diagnoses including sepsis (a life-threatening emergency caused by the body's extreme, harmful response to infection, often leading to rapid organ failure and death), hypertension (high blood pressure), and malnutrition. During an observation on 2/23/26 at 10:56 AM, Resident 26 was asleep in bed, with a catheter (a flexible tube used to deliver fluids into or withdraw fluids from the body) draining with yellowish urine to a drainage bag. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain a physician's (MD) order for oral suctioning for one of one sampled resident (Resident 14). This failure had the potential for Resident 14 not to receive appropriate treatment and services. Resident 14 was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD - a long-term lung disease that makes it hard to breathe) and pulmonary fibrosis (lung disease that occurs when lung tissue becomes damaged and scarred). During an observation on 2/23/26 at 10:22 AM, Resident 14 was asleep in bed, oral suctioning equipment was at resident's bedside table. The canister contained light yellowish secretions. During an interview on 2/25/26 at 10:44 AM, Hospital Aide (HA) 1 said that the oral suctioning equipment was used to suction secretions of Resident 14. [...]

Inspectors wroteBased on observation, interview, and record review facility staff failed to accurately measure a controlled drug to enable exact reconciliations. Certain medications/chemical substances are subject to strict government control/oversight due to their potential for misuse and harm. For example: Morphine to treat moderate to severe pain. Staff failed to accurately measure the amount of Morphine within a bottle upon receipt and during shift-to-shift verification. This failure had the potential for drug diversion and medication error.

Inspectors wroteBased on observation, interview, and record review facility staff failed to ensure a pharmacy printed label for a medication was legible. This failure had the potential for medication error.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for one of two sampled residents (Resident 14) when the Yankauer suction tip (a bulb-tipped instrument used to remove saliva, blood, and mucus from the oral cavity to maintain a clear airway and prevent aspiration) was not covered while not in use. This deficient practice had the potential to transmit microorganisms and increase the risk of infection for Resident 14. [...]

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to have a system in place to ensure the safe storage of residents' personal perishable food. This failure had the potential to result in foodborne illness for 18 residents who took food by mouth out of a facility census of 19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain a physician's (MD) order and develop a comprehensive care plan for the use of female external catheter for two of two sampled residents (Residents 158 and 201). This failure had the potential for residents to not receive appropriate treatment and services.

Inspectors wrote2. Resident was admitted on [DATE], with diagnoses including encephalopathy (a disturbance in the brain function causing confusion, memory loss), and dysphagia. During an observation on 8/5/24 at 11:00 AM, Resident 205, was in bed, had a tubing attached to a suction catheter, and a canister filled with whitish fluid connected to the suction machine. During an interview on 8/5/24 at 11:15 AM, with LVN 1, LVN 1 confirmed Resident 205 required suctioning on as needed (PRN) basis and stated, I did not suction him yet on my shift. During an interview on 8/7/24 at 10:20 AM, with RN 2, per RN2 suctioning is on PRN basis, the canister and suction tip should be changed every 2-3 days, will check the policy, date is important to know when to change the set. Review of Resident 205's clinical records, the OSR, there was no MD order for suctioning. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were assessed for risk of entrapment, risk and benefits for the use of bed rails were reviewed and bed rail assessment reflect the use of bed rails for three of eight sampled residents (Residents 151, 159, and 207). These deficient practices had the potential to put the residents at risk for entrapment, accidents, or injuries due to the use of bed rails.

Inspectors wroteBased on interview and record review, the facility did not send a copy of the reason for discharge to the office of the local Ombudsman, when one of two residents (Resident 2) was discharged to a lower level of care (board and care home).

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a comprehensive care plan (CP) that included measurable objectives and specific interventions for one of eight sampled residents (Residents 159) when there was no individualized person-centered CP for the use of Venlafaxine (medication used to treat depression) for Resident 159. This failure had the potential for not meeting the resident's nursing needs and goals to attain their highest practicable well-being.

Inspectors wroteBased on observation, interviews and record review, the facility did not provide daily, the nurse staffing information, when on 8/5/24, 8/6/24, and 8/7/24, there was no staffing data information posted.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of four sampled residents (Residents 158 and 159) were free from unnecessary psychotropic medication (drug that affect brain activities associated with mental processes and behavior) when there was no specific target behavior monitoring for the use of Venlafaxine (medication used to treat depression). This failure had the potential for residents to receive unnecessary psychotropic medication, be exposed to adverse health consequences from the medication, which could negatively impact the residents' mental, physical, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe medication storage practice in one of three medication carts (Med Cart, a locked mobile cart used to store medications and supplies) when several prescription medications were kept on top of a med cart and available for taking. This failed practice could contribute to unsafe medication storage and the potential for drug diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for one of two sampled residents (Resident 151) when the tip of the oral suction (involves inserting a small plastic tube attached to a suction machine into the mouth to remove saliva or mucus) tubing was touching the floor. This deficient practice had the potential to transmit microorganisms and increase the risk of infection for Resident 151.