Citrus Post-Acute

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the care plans were revised and the interventions were followed for two of three sampled residents (Residents 1 and 2). * The facility failed to revise Resident 1's care plan to reflect the refusals and/or non-compliance of the bowel regimens when the resident was not having regular bowel movements. * The facility failed to implement Resident 2's care plan interventions for pain. These failures posed the risk of the residents not receiving appropriate, consistent, and individualized care.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the appropriate care and services to prevent constipation for one of three sampled residents (Resident 1). * The facility failed to follow the physician's order for the bowel management when Resident 1 did not have a bowel movement for four days from 1/12/26 to 1/15/26. This failure had the potential for not providing the necessary care and services and posed a risk for adverse complications.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the resident's medical information was complete and accurate for one of three sampled residents (Resident 1). * The facility failed to ensure the turning and repositioning for Resident 1 was accurate. This failure had the potential to Resident 1 to receive inadequate care as the clinical information was not accurate.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive care plan was implemented to reflect the individual care needs for one of five sampled residents (Resident 1). * The facility failed to ensure Resident 1's risk for fall interventions for bilateral floor mats were implemented. This failure posed the risk of not providing appropriate, consistent, or individualized care to the resident.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development and worsening of pressure ulcer for one of five sampled residents (Resident 5). * The facility failed to update the physician's order for Resident 5's low air-loss mattress setting to the resident's current weight. This failure had the potential for the resident to develop pressure ulcers or worsening of existing pressure ulcer(s).

Inspectors wroteBased on interview, facility document review, and facility P&P review, the facility failed to thoroughly investigate the results of a background screening of a Medi-Cal excluded employee for one of two facility staff reviewed (RNA 1). * The facility failed to thoroughly investigate the exclusion status of a direct access employee that appeared on the new-hire background screening. This failure had the potential to compromise the safety of the residents in the facility.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive plan of care for one of three sampled residents (Resident 3) was revised to reflect the resident's current care needs and interventions. The facility failed to revise Resident 3's care plan to address the new interventions related to the management of weight loss. This failure posed the risk of not providing the resident with individualized and person-centered care.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure proper storage, labeling, and disposal of the medications. * The facility failed to ensure the temperature of Medication Storage room [ROOM NUMBER] was maintained within the acceptable range as per the facility's document. * The facility failed to ensure two open vials of tuberculin purified protein (used as a diagnostic test for inactive TB infection) were observed without an open date in the medication fridge in Medication Storage room [ROOM NUMBER]. * The facility failed to ensure the expired IV medications for Resident 37 were removed from the medication refrigerator in Medication Storage room [ROOM NUMBER]. [...]

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the food safety and sanitation guidelines were followed when: * The facility failed to ensure proper labeling and dating of food in the kitchen. * The facility failed to ensure the dented cans were sorted away from the intact cans. * The facility failed to ensure the food in the walk-in refrigerator was stored in a sanitary manner. * The facility failed to ensure the kitchen cooking equipment was air dried. * The facility failed to ensure the food preparation equipment was clean. * The facility failed to ensure the cutting board was free of corrosion. * The facility failed to ensure the maintenance tools were stored properly. * The facility failed to ensure there was a designated refrigerator to store the residents' food from the outside. [...]

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the education on safe food handling of outside food was provided to the residents and visitors as per the facility's P&P. In addition, the facility failed to ensure food brought to the facility by the family member were stored, and safe food handling practices were followed for one nonsampled resident (Resident 538). These failures had the potential to cause foodborne illnesses to the medically vulnerable resident population who consumed food brought from the outside sources.

Inspectors wroteBased on observation, interview, medical record review, facility document review and facility P&P review, the facility failed to maintain the infection prevention control program and practices designed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases and infections. * The facility failed to implement the infection control monitoring and surveillance for April 2025. * The facility failed to perform legionella testing per the facility's Legionella Water Management Program frequency. * The facility failed ton ensure Resident 131's contact enteric precautions were followed. * Staff''s personal cell phone was stored in the treatment cart with the residents' treatment supplies. * Staff placed their face-shield on top of an upside-down dirty linen cart lid. [...]

Inspectors wroteBased on interview, medical record review, facility record review, and facility P&P review, the facility failed to implement their antibiotic stewardship program including timely monitoring of antibiotic use. * The IP did not review antibiotics for appropriateness for April 2025 which showed 25 antibiotics were ordered. * The IP failed to notify Residents 14 and 26's physicians to re-evaluate the appropriateness of the residents' antibiotics when it was determined their suspected infections did not meet criteria. These failures had the potential of not accurately identifying true infections and exposing the residents to unnecessary antibiotic use.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the physician's order for code status matched the resident's POLST DNR status for one of seven final sampled residents (Resident 102) reviewed for advanced directives. * Resident 102 had a DNR status selected on the POLST signed by Resident 102's responsible party; however, the facility failed to ensure there was a physician's order for Resident 102's code status. This failure had the potential for not honoring the Resident 102's responsible party wishes and providing unwanted life sustaining interventions.

Inspectors wroteBased on observation and interview, the facility failed to maintain a homelike environment for one nonsampled resident (Resident 86). * Resident 86 resided in Room A. Resident 86 was observed sitting on his bed eating breakfast. A live pest (later identified as a water bug or roach) was observed on top of Resident 86's bed linen, next to Resident 86. This failure had the potential to negatively impact the resident's quality of life.

Inspectors wrote2. Medical record review for Resident 23 was initiated on 5/7/25. Resident 23 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 23's H&P examination dated 1/19/25, showed Resident 23 had no capacity to understand and make decisions. Review of Resident 23's Order Summary Report dated 5/9/25, showed the following physician's orders dated 4/4/25: - to monitor Resident 23's orthostatic BP sitting up every week on Wednesday, during the evening shift; and to notify the physician if there was a drop of 20 mmHg in the systolic BP, or a drop of 10 mmHg in the diastolic BP, - to monitor Resident 23's orthostatic BP lying down every week on Wednesday, during the evening shift; [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the physician's recommendation was carried out as ordered for one nonsampled resident (Resident 94). This failure had the potential of Resident 94 not receiving care as ordered.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the physician's order for a health shake with every meal for one of 30 final sampled residents (Resident 115). * Resident 115 had a physician's order to receive a four ounces of the health shake three times a day with meals. However, Resident 115 did not receive the health shake with meals. This failure had the potential to compromise Resident 115's nutritional status and posed the risk for negative health outcomes.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure five of eight final sampled residents (Residents 52, 65, 70, 84, and 537) and two nonsampled residents (Residents 40 and 90) reviewed for respiratory care were provided with the appropriate respiratory care and services when: * The facility failed to ensure Resident 40's storage bag for the nebulizer was changed weekly and PRN as per the facility's P&P. * The facility failed to ensure Resident 52's storage bag for the nebulizer was changed weekly and PRN as per the facility's P&P. * The facility failed to ensure Resident 65's nebulizer mask and the storage bag was changed every seven days. * Resident 70's nasal cannula was improperly stored, as evidenced by hanging from a portable oxygen tank instead of stored in a clean bag. [...]

Inspectors wroteBased on interview and medical record review, the facility failed to provide adequate and appropriate pain management for one of one final sampled resident (Resident 129) reviewed for pain management. * The facility failed to ensure the pain medication was administered as per the physicians' orders for Resident 129. This failure had the potential for Resident 129 not to receive the appropriate treatment for pain.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the necessary pharmaceutical services were provided to meet the needs for three of 30 final sampled residents (Residents 98, 102, and 104 (not in the roster)) and two nonsampled residents (Residents 7 and 90). * The facility failed to ensure accountability for the controlled medications (medications that have the potential for abuse or dependence) for Resident 102 when the hydromorphone (a controlled medication used to treat severe pain) HCl 2 mg tablet was signed out of the Resident 102's Controlled Medication Count Sheet but was not documented as administered in the MAR. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the medication side effects were monitored for the use of mirtazapine (antidepressant medication) for one of five final sampled residents (Resident 112) reviewed for unnecessary medications. This failure had the potential for Resident 112 to experience negative side effects of the mirtazapine medication without adequate monitoring.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure one of five final sampled residents (Resident 112) reviewed for unnecessary medications was free from unnecessary medications. * Resident 112 had a physician's order for clonidine (medication to treat hypertension) without an active diagnosis of hypertension (high BP). * Resident 112 was administered sodium chloride daily without regular blood work monitoring her sodium levels. These failures had the potential for Resident 112 to receive the medications unnecessarily and experience adverse effects which could negatively impact the resident's well being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below five percent. The facility's medication error rate was 26.67% for eight medication errors out of 30 medication administration observations. Three of four licensed nurses (LVNs 3, 4, and 6) observed during the medication administration were found to have made errors for one final sampled resident (Resident 102) and two nonsampled residents (Residents 40 and 43). * LVN 6 failed to ensure the potassium liquid medication given to Resident 102 via the GT was diluted as ordered by the physician. LVN 6 failed to ensure the medications were not administered together when administering medications via the GT to Resident 102, and to flush the GT in between the medications. [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure 133 of 137 residents who received food from the kitchen received the proper diets and portion sizes when the facility's menus were not followed. * The facility failed to ensure the new Vietnamese menu was posted and communicated to the residents who received Vietnamese menu meals. * The facility failed to ensure the kitchen staff served the correct portion size as per the menu and menu spreadsheet. These failures had the potential for the residents' nutritional needs not being met.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the nutritive content of the pureed foods for the Vietnamese menu, particularly the pureed stir fry vegetables, were preserved when the pureed vegetables were cooked and held on the steam table for two hours prior to meal service. This failure had the potential to not meet the nutritional needs of the five residents who received a Vietnamese menu pureed diet.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the coded MDS assessment was accurate for two of 30 final sampled residents reviewed for the MDS assessments (Residents 70 and 112). * Resident 112's MDS assessment was incorrectly coded for active diagnoses of hypertension (high blood pressure), hyponatremia (low sodium), and depression. In addition, Resident 112's MDS assessment was not coded to reflect the use of the antidepressant medication and was incorrectly coded to show the last attempted GDR for the use of antipsychotic medication on 2/6/25. * The facility failed to ensure Resident 70's MDS assessment Section I was accurately coded to include the resident's diagnoses of anxiety (disorder where intense feeling of worry and fear of everyday situations interfere with daily living) and depression (mood disorder). [...]

Inspectors wroteBased on interview and medical record review, the facility failed to coordinate an assessment with the PASARR program for one of two final sampled residents (Resident 70) reviewed for PASARR when the resident had a new diagnosis of anxiety and depression. This failure posed the risk for Resident 70 not receiving the necessary specialized services specific to treat mental illness.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the Level I PASARR contained accurate information for one of two final sampled residents (Resident 15) reviewed for PASARR. * Resident 15 had the diagnoses of psychosis, schizophrenia, and anxiety disorder; however the Level I PASARR showed Resident 15 had no serious mental illness. This failure posed the risk for Resident 15's inappropriate placement in a long-term care nursing home when a PASARR Level II evaluation was not done.

Inspectors wroteBased on interview, medical record review, and facility document review, the facility failed to ensure a comprehensive care plan was developed for one of 30 final sampled residents (Resident 49). * The facility failed to develop a care plan specific to Resident 49's ability to leave the facility (physician's out on pass order). This failure placed the resident at risk for not being provided appropriate, consistent, and individualized care.

Inspectors wroteBased on observation, interview, medical record review, facility document review and facility P&P review, the facility failed to ensure one final sampled resident (Resident 38) and one nonsampled resident (Resident 1) received the appropriate diet as ordered by the physician. * The facility failed to ensure Resident 1 was served soup with lunch as ordered by the physician. *The facility failed to ensure Resident 38's soup was the appropriate mechanically altered diet. In addition, the facility failed to ensure the extra entrée was provided with meals as ordered by the physician. These failures posed the risk of aspiration (inhalation of a foreign object into the airway and/or lungs) and the resident's nutritional needs not being met

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the medical records for four of 30 final sampled residents (Residents 41, 52, 84, and 98) and one nonsampled resident (Resident 66) were accurate. * The facility failed to ensure Resident 41's blood sugar levels were documented in the medical record. * The facility failed to ensure of Resident 52's POLST Section D was completed. * The facility failed to ensure Resident 84's POLST was signed and dated by the physician. * The facility failed to ensure Resident 66's Record of Death was complete and accurate. * Resident 98's blood pressure medication incorrectly documented as administered. These failures had the potential for the residents' care needs not being met as their medical information was inaccurate.

Inspectors wroteBased on interview, facility document review, and facility P&P review, the facility failed to ensure the QAPI committee implemented and monitored the effectiveness of their plan of correction for improvement of repeated deficient practice cited at F695, F761, F842, and F880. This failure had the potential to affect the quality of care for all the residents in the facility.

Inspectors wroteBased on observation, interview, medical record review, facility record review, and facility P&P review, the facility failed to protect the resident's right to be free from physical abuse by a resident for one of two sampled residents (final sampled resident, Resident 113) reviewed for abuse. * Resident 113 was hit in the face with a rehabilitation dowel by another resident (Resident 86). This failure resulted in Resident 113 suffering pain to the left side of his face and experiencing feelings of anger.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the daily fluid restriction for one of three sampled residents (Resident 2) was monitored and documented as ordered by the physician. This failurehad the potential to result in Resident 2 having an excess of fluid which could lead to negative health consequences due to impaired kidney function and the potential to negatively affect Resident 2's continuity of care while receiving dialysis at an outpatient dialysis center.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to develop and implement an individualized care plan for one of two sampled residents (Resident 1). * The facility failed to develop and implement an accurate care plan for Resident 1 to address the use of a PICC line. This failure posed the risk for Resident 1 having developed complications associated with the PICC.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the PICC line assessments were conducted and documented, failed to ensure the PICC unused lumens were flushed, and failed to conduct and document a change of condition assessment for the resident who exhibited pain and swelling at the PICC site for one of two sampled residents (Resident 1). These failures posed the risk for not identifying and treating potential complications associated with the PICC line, as evidenced by Resident 1 having sustained an occlusive right axillary deep vein thrombosis.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure Resident 1's medications were administered as ordered for one of two sampled residents (Resident 1). * Resident 1 did not receive the following medications as ordered by the physician due to a lack of availability: enoxaparin sodium (medication to prevent blood clots), levetiracetam (anti-seizure medication), desmopressin acetate (medication to treat cranial diabetes insipidus), and methocarbamol (muscle relaxant medication). * The facility failed to notify Resident 1's physician when Resident 1 did not receive his medications as ordered as per the facility's P&P. These failures posed the risk for negative health outcomes to Resident 1.

Inspectors wroteBased on observation, interview, medical record review, and facility document review, the facility failed to follow the infection control practices while cleaning the resident rooms for two of two sampled residents (Residents 1 and 2) and 10 nonsampled residents (Residents 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12.) * Housekeepers 1 and 2 did not use a new cloth while cleaning the individually used equipment between Residents 1, 2, 3, 4, 5, 6, 7, 8, and 9. * Housekeepers 1 and 2 did not wear a gown while cleaning the resident rooms with the EBP signage. * Housekeeper 1 scrubbed the toilet seats for Rooms A and B's shared restroom, and Room C's restroom with a toilet scrub brush for toilet bowl use only. * Housekeeper 1 failed to clean the restroom grab bars for Rooms A and B's shared restroom, and Room C's restroom. [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the kitchen staff were competent in the position related duties when: 1. Three of 11 kitchen staff (Cooks 1, 2 and DA 1) failed to follow proper hand hygiene. 2. Two of 11 kitchen staff (Cooks 1 and 2) failed to monitor and be competent in knowledge of the cool down procedure for TCS (time/temperature control for safety) foods. 3. One of 11 kitchen staff (Cook 2) failed to sanitize food preparation surfaces. 4. One of 11 kitchen employees (DA 1) failed to perform the following : a. DA 1 did not know the correct temperature of the rinse cycle of the dish machine, b. Demonstrate how to test the sanitizing solution of the dish machine according to the manufacturer guidelines, and c. [...]

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the nutritive content of the pureed foods for the American menu, in particular the pureed vegetables were preserved when the pureed vegetables were cooked and held in a hot oven more than one hour prior to meal service. This failure had the potential to not meet the nutritional needs of the 23 residents who received an American menu pureed diet.

Inspectors wroteBased on observation, interview, facility document review and facility P&P review, the facility failed to ensure food safety and sanitation guidelines were followed when: 1. The cool down process for time, temperature control for safety (TCS) food, food that need to be kept at specific temperatures to prevent bacteria growth and foodborne illnesses, was not monitored. 2. Food preparation surfaces were not sanitized properly. 3. A thawing process was not followed for meats. 4. Hand washing was not performed for three of eleven kitchen staff. 5. Food preparation equipment was not clean and in good working condition. 6. Hair restraints were not worn properly for six out of ten kitchen employees. 7. Kitchen equipment was not clean. 8. The kitchen environment was not clean. 9. The kitchen floor was not in a cleanable condition. 10. [...]

Inspectors wrote4. Medical record review for Resident 8 was initiated on 6/19/24. Resident 8 was admitted to the facility on [DATE], and readmitted on [DATE]. a. On 6/19/24 at 0900 hours, Resident 8 was observed lying in bed and the indwelling urinary catheter drainage bag was touching the floor. On 6/19/24 at 1000 hours, LVN 3 was summoned to the Resident 8's Room. LVN 3 verified Resident 8's indwelling urinary catheter drainage bag was touching the floor. LVN acknowledged the urinary collection bag should not be touching the floor. b. Review of the facility's P&P titled Enhanced Barrier Precaution dated 5/2024 showed the enhanced barrier precaution refers to an infection control intervention designed to reduce the transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to maintain the essential equipment in safe operating condition when: * The ice machine was not cleaned and sanitized in according to the manufacturer specifications. * The dish machine water temperature was below the manufacturer specifications for the wash and rinse cycles. * A metal screen door on the back door of the kitchen was not flush with the door jamb creating a gap. * A screen above a food preparation counter was not intact. * A fire sprinkler on the ceiling of the walk-in refrigerator had a brown residue resembling rust and was not intact with the ceiling of the walk-in refrigerator. These failures had the potential for the essential equipment to not function in the way it was intended.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the informed consents were obtained prior to the use of the psychotropic medications (medications affecting brain activities associated with mental processes and behavior) for two of six final residents (Residents 32, and 540) reviewed for psychotropic medication use . * The facility failed to ensure an informed consent was obtained prior to administering the iloperidone medication (antipsychotic medication) for Resident 32. * The facility failed to ensure an informed consent was obtained prior to administering the lorazepam medication (antianxiety medication) for Resident 540. These failures had the potential for Residents 32 and 540 to not be informed of the psychotropic medications, and the potential side effects of the medications.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to determine if it was safe for one of 27 final sampled residents (Resident 95) to self-administer the medications. * Resident 95 was observed with the medications at bedside. Resident 95 did not have a physician's order, assessment, and care plan for the self-administration of medications. This failure had the potential for Resident 95 to administer the medications inaccurately.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to promote the dignity and respect for two of 27 final sampled residents (Residents 81 and 540) and one nonsampled resident (Resident 96). * The call light was not within reach for Residents 81, 96, and 540. This failure created the potential to result in a delay to provide care and negatively impact the resident's psychosocial well-being.

Inspectors wroteBased on interview and medical record review, the facility failed to clearly identify the current code status for one of seven final sampled residents (Resident 32) reviewed for advance directives. * The facility failed to clarify and honor Resident 32's desire to have a full code status. In addition, the facility failed to ensure the correct individual signed Resident 32's POLST. Resident 32's POLST showed Resident 32 was a DNR and another individual (not Resident 32) signed Resident 32's POLST. These failures had the potential to not provide care in accordance with the resident's treatment wishes.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one of 27 final sampled residents (Residents 8) and one nonsampled resident (Resident 107). * The facility failed to follow the physician's order for Resident 8 to administer the antibiotic as ordered intravenously. This failure created the risk of not providing the appropriate care for Resident 8. * The facility failed to follow the physician's order for Resident 107 to receive a health shake (nutritional suppplement)with meals. This failure posed the risk for Resident 107 to not receive adequate calories which could lead to weight loss.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the post fall assessments were appropriately completed for two of three residents (Residents 42 and 124) reviewed for falls. * Resident 42's post fall neuro checks were incomplete for two falls. * The facility failed to continue to monitor and document assessment every shift for 72 hours post fall incident for Resident 124. These failures had the potential to delay identifying and responding to post fall changes.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to accurately monitor the hydrations status for one of 27 sampled residents (Resident 539). * The facility failed to ensure accurate monitoring of Resident 539's fluid intake which included from meals, medication administration, free water, liquid supplements, IV (intravenous) hydration, IV therapy intake, and IV flushes. In addition, the facility failed to ensure the monitoring of Resident 539's fluid output showed the actual number of urine output from the resident's indwelling catheter, and not just the frequency of voiding. These failures had the potential to compromise Resident 539's hydration status and posed the risk for negative health outcomes.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the intravenous accesses for one nonsampled resident (Resident 12) and one of one final sampled resident (Resident 539) reviewed for IV devices. * The facility failed to ensure the PICC line external catheter and arm circumference measurements were performed and documented in the medical record for Residents 12. * The facility failed to ensure the external catheter length and arm circumference measurements were performed as per the resident's plan of care. In addition, the facility failed to ensure Resident 539's midline catheter (an eight to twelve cm catheter inserted in the upper arm with the tip located just below the axilla) dressing was not soiled and dated. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure five of five residents (Residents 8, 12, 16, 79, and 86) reviewed for respiratory care were provided the appropriate respiratory care when: * The facility staff administered oxygen to Resident 8 without a physician's order and care plan to address oxygen use and monitoring of oxygen saturation level when the resident was using the oxygen continuously. *The facility failed to ensure Residents 12 and 86's nasal cannula (flexible tube to deliver oxygen to the nose) tubing were dated, labeled, and not touching the floor for Resident 12. *The facility failed to ensure Resident 16's CPAP (continuous positive airway pressure, a machine that uses mild air pressure to keep breathing airways open) mask was stored in a bag when not in use. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the pharmaceutical services were provided to meet the needs of the residents for two of five residents (Residents 7 and 23) reviewed for unnecessary medications and one nonsampled resident (Resident 339). In addition, the facility failed to ensure the process for opening the E-kit was followed and failed to ensure the controlled count were documented each shift. * The facility failed to ensure Resident 7's carvedilol, losartan, and furosemide (medication to treat high blood pressure) were administered and held as ordered. * The facility failed to ensure Resident 7 had an insulin coverage for blood sugar results between 351-401 mg/dl, and had a physician's order to notify the physician for blood sugar of less than 70 mg/dl. [...]

Inspectors wroteBased on interview and medical record review, the facility failed to ensure four of five final sampled residents (Residents 7, 17, 78, and 540) reviewed for unnecessary drugs were free from unnecessary drugs. * The facility failed to ensure Resident 540's heart rate was checked prior to administering the amiodarone (a medication that works directly on the heart tissue and slows the nerve impulses in the heart) and carvedilol (a medication that works by affecting the nerve impulses in the body such as the heart, and slows the heart beat and decreases blood pressure) medications nor the resident's blood glucose checked prior to administering insulin glargine (a long-acting insulin) as per the physician's orders. * The facility failed to ensure Resident 7's order for losartan (medication to treat high blood pressure) and ProStat had diagnoses for the medications ordered by the physician. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure two of five final sampled residents (Residents 7 and 540) reviewed for unnecessary drugs were free from unnecessary psychotropic drugs (any drug that affects brain activity associated with mental processes and behavior). * The facility failed to ensure the physician's order for lorazepam (antianxiety medication) 0.5 mg as needed for Resident 540 was limited to a 14-day duration. In addition, the facility failed to show documentation by the attending physician or prescribing practitioner for the rationale for the extended time in the medical record. Furthermore, the facility failed to develop a care plan to address the lorazepam use. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. * The facility's medication error rate was 10.34%. One of three licensed nurses (LVN 7) was found to have made errors during the medication administration observation for two nonsampled residents (Residents 66 and 339). This failure had the potential to negatively impact the resident's heal outcomes.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure proper medication storage. * The facility failed to properly label an opened tuberculin solution with the open date to include the year it was opened. * The facility failed to remove the expired dextrose (a sterile solution used to provide the body with extra water and carbohydrates) injection solution. * The facility failed to remove the expired Heparain (blood thinner to prevent clots) lock flush solution. * The facility failed to store Gamunex-C (medication used to strengthen the body's natural defense system to lower the risk of infection in persons with a weakened immune system) 10% vials as per storage instructions. * The facility failed to ensure the refrigerator containing medications was kept in sanitary condition. [...]

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the Certified Dietary Manager (CDM) who was responsible to oversee the food services department was competent in managing the day-to-day functions of the food services department. Failure to employ staff with the skills and abilities to effectively implement departmental processes in accordance with standards of practice, may jeopardize the health and well-being of the 122 residents who received food prepared in the kitchen.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the American and Vietnamese menus met the resident's nutritional needs when * The Vietnamese menus did not have puree recipes. * The Vietnamese menus did not have a nutritional analysis. * The Vietnamese menus were not updated periodically. * The Vietnamese menus did not reflect the standard of practice for IDDSI (International Dysphagia Diet Standardization Initiative). * The American menu puree recipes were not followed for puree ham, puree green peas, and puree sweet potatoes. * The facility failed to ensure the coleslaw was served to Residents 51 and 115 as per the spreadsheet. * The facility failed to ensure lettuce, tomato, and onions with the hamburger were served to Resident 16. [...]

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to provide a meal substitute equivalent in nutritive value when: * The pureed ham served to 23 of 122 residents who received an American menu puree diet had a higher sodium content than the regular ham and, * The grilled cheese sandwich served to Resident 7 was not equivalent in protein to the entrée served. Theses failures had the potential for residents who received a meal alternate from the kitchen to not meet their nutritional needs.

Inspectors wroteBased on interview and facility P&P review, the facility failed to ensure food brought to the facility by the family members or visitors was stored and prepared; and safe food handling practices were followed. This failure had the potential for unsafe food handling which could lead to food borne illness.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the complete and accurate medical records for four of 27 final sampled residents (Residents 7, 23, 56, and 540) and one of three closed record sampled residents (Resident 138). * Resident 7's POLST was not included in their medical record. * Resident 56's POLST was incomplete and did not show if the resident had an advanced directive. * Resident 540's POLST was not updated to show the resident had advance directive. * Resident 23's MAR was incomplete for medication administration. * Resident 138's medical record failed to show a CPR was initiated prior to paramedics' arrival. These failures had the potential for resident's care needs not being met as the clinical information were incomplete and/or inaccurate.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the residents' entrapment assessments were complete and the measurements were recorded during the bed inspection when identifying areas of possible entrapment with the use of side rails for three of three residents (Residents 30, 79 and 87) reviewed for side rails. These failures had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the kitchen and dining room were free of pests. This failure posed the risk of the residents residing in the facility to be exposed to pests.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the comprehensive plans of care for two of 27 final sampled residents (Residents 30 and 32) reviewed for care plans were revised to reflect the residents' current care needs and interventions. * Resident 32's plan of care was not accurately updated to reflect the resident's full code status. * Resident 30's plan of care was not revised to reflect Resident 30's wound care interventions. These failures posed the risk of not providing the residents with individualized and person-centered care.

Inspectors wroteBased on observation, interview, and facility P&P, the facility failed to ensure the garbage was disposed properly when the cooked beans and egg shell were found on the ground at the back door of the kitchen. This failure had the potential to attract pests/rodents that carry diseases.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to develop the comprehensive plan of care to reflect the individual care needs for one of three sampled residents (Resident 1). * The facility failed to develop a care plan problem to address Resident 1's allergy requiring medication. This failure posed the risk of not providing appropriate, consistent, and individualized care to Resident 1.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the comprehensive plan of care for one of three sampled residents (Resident 1) was revised to reflect the resident's current care needs and interventions. * The facility failed to revise Resident 1's care plan to address the change in insulin and monitoring of blood sugar. This failure posed the risk of not providing the resident with appropriate, consistent, and individualized care individualized and person-centered care.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to monitor the blood sugar levels daily for one of three sampled residents (Resident 1) were free from unnecessary drugs. This failure had the potential to adversely affect and negatively impact the resident.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the residents' medications were stored properly for one of three sampled residents (Resident 1). * The facility failed to ensure the nasal spray was stored properly for Resident 1 when Flonase allergy relief nasal suspension was observed on Resident 1's overbed table. This failureposed the potential for unauthorized access to the medications, medication error, and negatively affected the residents' well-being.

Inspectors wroteBased on interview, medical record review, facility record review, and facility P&P review, the facility failed to implement their P&P for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B as evidenced by: * The facility failed to ensure Resident 3's sexual abuse allegation was reported timely to the CDPH L&C Program and local law enforcement for one of six sampled residents (Resident 3). This failure had the potential for abuse allegations to go unreported and uninvestigated timely.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to implement the P&P for reporting the investigative findings to the CDPH, L&C Program within five working days for an allegation of staff to resident abuse for one of six sampled residents (Resident 1). This failure had the potential for the abuse allegation going unreported and uninvestigated.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the low air loss mattress for one of six sampled residents (Resident 6) was kept at the correct settings for the resident. This failure posed the risk of the resident not receiving appropriate care.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure one nonsampled residents (Resident D) was invited to his care plan meetings when there was no documented evidence Resident D was present during his last two care plan meetings. This failure posed the risk of Resident D not being able to participate in his plan of care.

Inspectors wroteBased on interview, medical record review, and facility document review, the facility failed to allow one of four sampled residents (Resident 2) to return and resume residence in the facility after the acute care hospital determined Resident 2 was ready for discharge from the acute care hospital. This failure caused Resident 2 to remain in the acute care hospital for approximately an additional 10 days, which had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility document review, the facility failed to ensure the necessary care and services were provided to prevent the worsening of pressure injuries for one of four sampled residents (Resident 3). This failure had the potential to cause the pressure injury to get worse. * Resident 3's pressure injury was not measured and assessed weekly. In addition, the licensed nurse did not notify the wound specialist to evaluate Resident 3's wound.

Inspectors wroteBased on interview, medical record review, and facility document review, the facility failed to ensure to assess or identify fall risk for one of eight sampled residents (Resident 8). * Resident 8 was admitted to the facility after a fall with fracture. Resident 8 had unsteady gait and poor balance. The facility failed to assess or identify the fall risks to develop the plan of care to prevent falls. This failure created the risk to not provide the necessary care and services to prevent falls for this resident.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the food storage and delivering met the standards of safety and sanitation requirements. * The facility failed to ensure the boxes of fruits in the walk-in refrigerator were labeled with received dates. * The facility failed to ensure the opened bottle of spices on the kitchen shelves were labeled with the opened dates. * The facility failed to ensure the food items were covered when transported from the kitchen to the resident rooms for one sampled resident (Resident 43) and one nonsampled resident (Resident 79). These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to implement their infection control program and practices designed to help prevent the development and transmission of diseases and infections. * The facility failed to accurately identify and conduct the surveillance of residents with HAIs and CAIs from July 2021 through December 2021. The facility documented 215 resident infections (CAIs and HAIs) from July 2021 through December 2021. The facility failed to classify infections as CAIs for the residents who met McGeer's criteria within 72 hours of admission. This failure posed the risk for inaccurate infection surveillance data used to identify, manage, and contain infectious diseases. * LVN 4 failed to perform hand hygiene during the medication administration for Resident 665. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 25 final sampled residents (Resident 35) was assessed to determine if the resident was safe to self-administer the medications. This failure had the potential to negatively impact the resident's physiological well-being and posed the risk of medication administration errors.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to develop and implement the comprehensive care plans for two of 25 final sampled residents (Residents 42 and 83). * The facility failed to implement Resident 42's care plan for the use of bilateral floor mats. Resident 42 had poor safety awareness and a history of falls in the facility. * The facility failed to develop a comprehensive plan of care to address the use of a Podus boot for Resident 83. Resident 83 had been wearing a Podus boot (a medical brace used to prevent and manage heel pressure and foot drops) to her left lower leg. These failures posed the risks for the residents not receiving the necessary care and services.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive care plan was revised for one of 25 final sampled residents (Resident 42). * The facility failed to ensure Resident 42's comprehensive care plan was revised to reflect a physician's order for a change of Resident 42's diet from a mechanical soft texture to pureed texture. This failure placed the residents at risk of not being provide appropriate, consistent, and individualized care.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the necessary care and services to prevent the skin breakdown for one of 25 final sampled residents (Resident 83). * The facility failed to ensure the physician's order for wound consultation was carried out. This had the potential for the resident to develop further skin breakdown and not receive the appropriate care and services to promote wound healing.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide safe respiratory care for three of 25 final sampled residents (Residents 85, 110, and 364). * Residents 85 and 110's oxygen rates were not administered as ordered by the physician. Residents 85 and 110's oxygen tubings were on the floor. Resident 110's oxygen tubing was not dated to show when it was last changed. * The facility failed to ensure Resident 364's nebulizer mask was stored in a sanitary manner. The facility's practice for storage of the resident's nebulizer mask consisted of storing the mask in a clean plastic bag; however, Resident 364's nebulizer mask was observed lying directly on a nightstand. These failures posed the risk for equipment contamination and respiratory complications.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary pharmaceutical services to meet the needs for two nonsampled residents (Residents 15 and 665). * LVN 4 failed to provide the necessary instructions to Resident 665 when he administered Combivent Respimat (inhalation spray to treat and prevent symptoms, wheezing and shortness of breath caused by ongoing lung disease). This failure had the potential to result in an incomplete drug dose administration for Resident 665. * The facility failed to ensure accurate reconciliation of the controlled medications for one Resident 15. LVN 5 failed to document in the MAR when he administered Resident 15's lorazepam (anti-anxiety medication). Resident 15's Controlled or Antibiotic Drug Record did not reconcile with the MAR. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility document review, the facility failed to ensure the medication error rate was below 5%. The medication error rate was 10%. * LVN 4 failed to wait for 5-10 minutes in between the administration of Resident 655's three eye drop medications. This failure had the potential for drug interactions that may negatively affect the resident's wellbeing.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to provide the pharmaceutical services to meet the needs of each resident. * Expired medications and supplies were stored in the medication storage rooms available for resident use. This failure had the potential to expose the residents to medications and supplies, which could be compromised or ineffective.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure a system was in place to accurately verify the ordered diets for four of 25 final sampled residents (Residents 7, 20, 42, and 61) and four nonsampled residents (Residents 5, 56, 400, and 401). * Resident 42 received and consumed a mechanical soft textured diet, however, the physician's order showed Resident 42 was to receive a pureed textured diet. * Residents 5, 7, 20, 56, 61, 400, and 401's diet orders printed in their meal tickets did not match the physician's order. These failures had the potential to lead to choking or aspiration (a condition in which food, liquids, saliva, or vomit is breathed into the airway) and posed the risk for residents to receive inadequate nutrition.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to maintain a safe and sanitary environment for the residents and staff. * The facility failed to ensure the boxes of foam plates and foam cups were properly stored in the dry storage room. This failure posed a potential safety hazard for the residents and staff.

Inspectors wroteBased on observation and interview, the facility failed to ensure the garbage and refuse were properly stored in one of three garbage dumpsters. The garbage dumpster was overflowing with garbage, which prevented the lid from fully closing. Failure of the facility to keep the garbage covered had the potential to attract pests/rodents that carried diseases.