Colonial Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a debris-free dumpster area when trash was not properly contained, covered, and free from overflowing for three of three trash dumpsters. This failure had the potential to result in pests (an organism that causes harm to humans such as flies, cockroaches, and rodents) entering the facility and spreading diseases to the residents.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents, who were identified at risk for fall, did not fall and sustained injury for one of three sample residents (Resident 8 and Resident 44). The facility failed to: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of eight sampled residents (Resident 9), who was receiving hemodialysis (dialysis, a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) :Physician orders for specific fluid allowed in 24 hours were placed. Fluid intake was being measured. These deficient practices had the potential to place residents at risk for fluid retention and overload.

Inspectors wroteBased on interview, and record review, the facility failed to Identify and to intervene in two of three sampled residents (Resident 17 and Resident 156)' history of trauma and triggers which may cause re-traumatization (a person encounters a new event or stimulus that triggers them to re-experience the intense stress, emotional distress, and even flashbacks of a previous traumatic event as if it were happening again) as evidenced by:A. Failing to assess and identify the trauma and triggers for Resident 17 related to natural/human caused disaster. B. Failing to assess and identify the trauma and triggers for Resident 156 related to homelessness. This failure had the potential to result in Resident 17 and Resident 156 experiencing re-traumatization and further psychosocial decline.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of five sample residents (Resident 73 and Resident 99): Obtained consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) that explains the risk and benefits of bed rails (are adjustable metal or rigid plastic bars that attach to the bed) with the resident representative prior to installation. was offered other alternative attempts prior to installing side rails. These failures had the potential to result in compromised resident safety associated with unassessed bed rail use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%). Three errors out of 29 opportunities contributed to an overall error rate of 10.34 % affecting two of five residents observed for medication administration (Residents 92 and 97). The errors noted were as follows:Incorrect strength of ferrous sulfate (an iron supplement) administered to Resident 97Incorrect formulation of multivitamins (a vitamin supplement) administered to Resident 97Incorrect strength of ferrous sulfate administered to Resident 92 The deficient practice of failing to administer medications in accordance with the physician's orders or professional standards increased the risk that Residents 92 and 97 may have experienced medical complications possibly resulting in hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food safety, sanitary food storage and food preparation practices. These failures have the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to food borne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control measures by failing to:1. Ensure Certified Nurse Assistant (CNA) 2 did not pick up Resident 186's contaminated cloth from hallway floor and place in the resident's closet without washing.2. Follow Enhanced Barrier Precaution [EBP-an infection control measures, primarily in nursing homes, requiring staff to wear gowns and gloves during high-contact care for residents with multidrug-resistant organisms or increased risk factors like wounds/devices, expanding beyond Standard Precautions to prevent multidrug-resistant organism (MDRO) spread where direct contact is likely] while handling dirty bed linens for Resident 175. These failures had the potential to result in compromised infection control measures to prevent the spread of infection among residents, staff, and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain a complete a written informed consent (voluntary agreements to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for the use of physical restraints (devices that limit a resident's movement) prior to the use of padded bilateral upper side rails for one of one sampled resident (Resident 196). This failure resulted in a violation of Resident 196's right to be informed and participate in treatment decisions.

Inspectors wroteBased on interview and record review, the facility failed to ensure Advance Directives ([AD]-written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) were discussed and written information was provided to the residents and/or responsible parties and had a completed Physician Orders for Life-Sustaining Treatment ([POLST]- a medical order that helps give people with serious illness more control over their care during a medical emergency) for one of three sampled residents (Resident 18) in the medical records. These failures had the potential for delay of care and treatment and/ or inadvertently missed health care wishes/ decisions of the residents during emergencies, end of life, and changes in condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the nursing staff notified the physician in a timely manner when one out of three residents (Resident 122) refused tube feeding (a method of delivering liquid nutrients, fluids, and medications directly into the stomach or small intestine via a flexible tube) for the day. This deficient practice placed Resident 122 at risk for potential weight loss and malnutrition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the resident's right to be free from physical abuse when Resident 96 pushed Resident 44, causing Resident 44 to fall to the ground. This deficient practice resulted in Resident 44 falling and sustaining a traumatic skin tear measuring 1 centimeter (cm unit of measure of length) long by x 0.1 cm wide on the right eyebrow, requiring an emergency visit to a General Acute Care Hospital (GACH) for treatment and management.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure Minimum Data Set (MDS- a resident assessment tool) accurately reflects resident status for two of five sampled residents (Resident 73 and Resident 99). This failure had the potential to result in inaccurate assessment of the resident's condition, leading to inappropriate care planning, monitoring and interventions.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement the nursing interventions according to the care plan for one of three sampled residents (Resident 99). This deficient practice had the potential for Resident 99 needs not being met.

Inspectors wroteBased on interview and record review, the facility failed to follow the care plan and implement nonpharmacological interventions (any healthcare intervention not involving medications) for pain for one of eight sampled residents (Resident 20). This deficient practice had the potential to place the resident at risk for ineffective pain management and untreated pain.

Inspectors wroteBased on interview and record review, the facility failed to ensure nursing staff used behavioral signs of pain (observable non-verbal actions that indicate distress such as facial grimacing, moaning, irritability) to assess pain for one of eight sampled residents (Resident 20). This deficient practice had the potential to result in inaccurate pain assessments and untreated pain.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 15) received Restorative Nursing Assistant ([RNA], a certified nursing assistant who works with patients in skilled nursing facilities to help them regain their ability to perform daily tasks) services ordered for the resident. This deficient practice had the potential to negatively have a decline in range of motion and mobility leading to contractures.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the tube feeding (a method of delivering liquid nutrients, fluids, and medications directly into the stomach or small intestine via a flexible tube) machine was on and functioning properly to administer the feeding for one of three sample residents (Resident 5) when the tube feeding machine was on but not administering the feeding to Resident 5 for over three hours. This deficient practice placed Resident 5 at risk for weight loss and nutritional deficit.

Inspectors wroteBased on observation, interview, and record review the facility failed to store two unopened Humalog insulin pens (a medication used to treat high blood sugar) in the refrigerator per the manufacturer's requirements affecting Residents 160 and 207 in one of five inspected medication carts (Station 3 Cart A.)The deficient practices of failing to store unopened insulin pens in the refrigerator per the manufacturer's requirements increased the risk that Residents 160 and 207 could have received medication that had become ineffective or toxic due to improper storage possibly leading to health complications resulting in hospitalization or death.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 18) who was under hospice care (compassionate care for people who are near the end of life provided at the person's home or within a health care facility) was visited by hospice licensed nurses weekly per hospice care agreement. This failure had the potential to result in Resident 18 not having their hospice needs met, as they agreed upon.

Inspectors wroteBased on interview and record review, Licensed Vocational Nurse (LVN) 1 failed to assess the mobility limitations and take precautions before moving one of three sampled residents (Resident 1), who was dependent on staff to roll from the left to the right side. The facility failed to ensure: LVN 1 requested assistance from another staff member before repositioning Resident 1, who per the Minimum Data Set ([MDS] a resident assessment tool), was dependent on staff to roll from the left side to the right and or the assistance of two or more helpers was required for Resident 1 to roll from the left to the right side. This deficient practice resulted in LVN 1 repositioning Resident 1 without assistance and hitting Resident 1's right knee on the resident's bed frame. [...]

Inspectors wroteBased on interview and record review, the facility failed to report immediately and not later than two hours after receiving an allegation of physical abuse (any intentional act causing injury or trauma to another person by way of bodily contact) by one of fifteen sampled residents (Resident 4) to officials, including the State Survey Agency and law enforcement. This deficient practice resulted in the inability of The California Department of Public Health (CDPH) to investigate the allegations of abuse in a timely manner and placed Resident 4 at risk for continued physical abuse.

Inspectors wroteBased on observation, interviews and record reviews, the facility did not provide timely medical intervention and transferred to a general acute care hospital (GACH) for one of three sampled residents (Resident 1) who experienced a significant change in condition related to unmanaged pain and delayed treatment. The facility failed to: 1. Notify Resident 1's physician promptly after receiving an order for right hip and right femur (the bone of the thigh or upper hind limb, articulating at the hip and the knee) x-ray (images of the inside of the body) result on 10/22/2025 at 1:22 a.m. indicating an acute (a condition that sudden) proximal (point of attachment) femoral (hip) fracture (broken bone) with soft tissue swelling (accumulation of fluid in the body's muscles and is a sign of inflammation caused by injury). The physician was not notified until 8:35 a.m., over seven hours later. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) bed was placed in a low position, per the resident's Falling Star Program care plan dated 2/13/2024. This failure has resulted in Resident 1, who was assessed as a high risk for falls, being observed in a bed that was not in a lowered position and placed Resident 1 at risk for falling out of bed and injuries.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident with a Full Code status (resident wants all life saving measures in case of life threatening emergencies) and in distress, received Cardiopulmonary Resuscitation (CPR-an emergency procedure to restart a person's heart, chest compressions) immediately, reducing the residents chances of survival and adverse health outcomes for one of 145 residents with Full Code status (Resident 44). The facility failed to: 1. Ensure Registered Nurse (RN) 2 announced a Code Blue (an announcement that signifies a medical emergency where a patient is experiencing a life-threatening situation) when Resident 44 had no palpable (rhythmic beat of a blood vessel indicating a heartbeat, that can be felt by touch) heartbeat. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident, who was receiving feeding through a gastrostomy tube ([GT] a soft tube surgically placed into the stomach to provide nutrition and medications), did not have a severe weight loss (a weight loss greater than five percent (%) in one month, or greater than 7.5% in three months, and greater than 10% in six months) for one of 48 residents receiving GT feeding (Resident 188). The facility failed to ensure: 1. [...]

Inspectors wroteBased on observation ,interview and record review the facility failed to ensure they followed their own sanitation and infection control policy to work under sanitary conditions at all times. This deficient practice had the potential to result in cross-contamination (transfer of harmful substances or disease-causing microorganisms to food by hands, food contact surfaces) and increase the risk of infection for 133 of 181 residents.

Inspectors wroteBased on observation and interview the facility failed to ensure to store food in a sanitary manner to prevent growth of microorganisms that could cause food borne illness (food poisoning: any illness resulting from the food spoilage of contaminated food, pathogenic bacteria, and viruses for 133 out of the 181 residents in the facility by not: 1. Facility failed to separately store frozen meats and veggies. 2. Facility failed to store opened sausages and croissants separately in the produce fridge. 3. Facility failed to date and label frozen items, produce, and stored goods. 4. Facility failed to date thickened milk shakes that were already thawed in the fridge. 5. Facility failed to discard molded and expired bread and expired cottage cheese. 6. Facility failed to check chloride levels and have chloride test strips available before running the dishwasher. 7. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose garbage and refuse properly by not completely covering two (2) of three (3) blue dumpster (a large trash container designed to be emptied into a truck) for unknown amount of time. This deficient practice had a potential to attract flies, insects, cats, and other animals to the dumpster area placing 180 of 196 facility residents getting food from the kitchen cross-contamination (a transfer of harmful bacteria from one place to another).

Inspectors wroteBased on observation, interview and record review, the facility failed to offer, educate, and track coronavirus vaccinations for staff per facility's policy. This failure had the potential to place all residents at risk for infection of coronavirus.

Inspectors wroteBased on interview, and record review, The facility failed to provide Effective Communications training for direct care staff, including 18 of Registered Nurse (RN), 50 of Licensed vocational nurse (LVN), and 20 of Respiratory Therapist (RT) as required by the facility's policy and procedure (H&P). This deficient practice had the potential to miscommunication, unmet resident needs, and compromised care, particularly for residents who rely on alternative communication methods.

Inspectors wroteBased on interview, and record review, The facility failed to provide Quality assurance and performance improvement (QAPI) training for direct care staff, including 18 of Registered Nurse (RN), 50 of Licensed vocational nurse (LVN), and 20 of Respiratory Therapist (RT) as required by the facility's policy and procedure (H&P). This deficient practice had the potential to result in poor communication among staff, lack of awareness of facility updates, lack of collaborative work, and compromised resident care.

Inspectors wroteBased on interview and record review the facility failed to: a. involve one of 10 sampled residents (Resident 188) and his responsible party, family member (FM 1) in creating a plan of care for significant weight loss. b. ensure one of seven sampled residents (Resident 19) participated in the development and implementation of his care plan by failing to ensure Resident 19 was involved in the care planning process when Restorative Nursing Aide (RNA, nursing aide program that helps residents maintain their function and joint mobility) services for range of motion (ROM, full movement potential of a joint) exercises to both legs were discontinued. These deficient practices caused Resident 188 and FM 1 to not be informed regarding Resident 188's current health condition and Resident 19's right to be active participant in his care.

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents' medical records were updated to show documentation that a resident has an advance directive (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) for four of eight of sampled residents (Resident 37, 343, 55, and 46). This deficient practice had the potential to cause conflict with the residents' wishes regarding health care. 1. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to: a. Notify one out of 10 sampled residents (Resident 188)'s physician (MD 1) and responsible party (FM 1) when Resident 188 had a change of condition related to significant weight loss of 7.6% (9lbs) in one month on 1/3/2025, and 20.1% (24lbs) weight loss in 2 months on 1/31/2025. b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow facility's policy and procedure by: 1. Failing to find alternative ways to prevent fall before putting the 4 side rails up for Resident 24 and placing lap tray over Resident 161 2. Failing to obtain consents before applying restraints. 3. Failing to conduct a pre-restraining assessment and review to determine the need for restrains. 4. Failing to follow resident's care plan to have IDT meeting to discuss plan of care and to ensure appropriateness of restraint. This failure has the potential to compromise the resident's dignity and safety, create un unsafe environment, and increase the risk of further injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of three sampled residents (Residents 16 and Resident 55) Preadmission Screening and Resident Review (PASRR) assessment screening was accurate to determine the facility's ability to provide the special need of the residents. This deficient practice placed the residents at risk of not receiving necessary care and services they need.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nine out of 37 sampled residents (Resident 19, Resident 21, Resident 25, Resident 40, Resident 46, Resident 55, Resident 59, Resident 74, and Resident 188) had a person-centered care plan related to: 1. The facility failed to develop and implement a care plan for Resident 19's refusal of Restorative Nursing Aide (RNA, nursing aide program that helps residents maintain their function and joint mobility) services for passive range of motion (PROM, movement at a given joint with full assistance from another person) exercises to both legs. 2. Facility failed to initiate and update care plans for resident 46 for actual seizures and seizure medications. 3 . Failed to initiate care plans for Resident 55 and Resident 21 for continued weight loss. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatments and services to five of seven sampled residents (Residents 19, 37, 66, 95, and 109) to prevent and/or limit a decline in joint (where two bones meet) range of motion (ROM, full movement potential of a joint) and mobility (ability to move). 1. For Resident 95, the facility failed to ensure the Restorative Nursing Aide (RNA, nursing aide program that helps residents maintain their function and joint mobility) order for the application of a resting hand splint (RHS, splint secured from the hand to the forearm to position the hand in a functional position) to Resident 95's left hand was written appropriately to include a maximal wear time of two (2) hours. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure tube feedings were properly managed for three (3) of four (4) sampled residents (Resident 16, 84, and 37) with a gastrostomy tube (GT or g-tube: a tube that is passed through the abdominal wall to the stomach used to provide nutrition) by failing to: 1. Ensure Resident 16's tube feeding was disconnected after the administration of feeding. 2. Ensure the feedings were replaced in a timely manner for Residents 84 and Resident 37 that were hanging and were not administered for more than 24 hours (hrs) later. These deficient practices had the potential to place Residents 16, 84, and 37 at risk for infection. 1. [...]

Inspectors wroteBased on interview and record review the facility failed to 1. Ensure Restorative Nurse Assistant (RNA 1) was competent regarding documenting residents' weight in the resident's medical record and licensed nurses (unknown) including Registered Nurses (RN 2 and RN 3) were competent in reporting changes of condition related to weight loss to the registered dietician (RD), physician (MD 1), and the responsible party (Family Member (FM)1) for one of 10 sampled residents (Resident 188). These deficient practices had the potential to cause inaccurate nutrition assessments and the potential for a delay in care and implementation of interventions to prevent further weight loss for Resident 188. Cross reference:

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure Resident 177's physician order for Aspirin [a medication used to prevent heart attack (flow of blood and oxygen is blocked) and stroke (loss of blood flow to a part of the brain)] was administered as a chewable according to manufacturer formulation specifications instead of being swallowed, on 2/5/2025. 2. Ensure the correct medication administration route (is often classified by the location at which the drug is administered) was ordered for one of eight sampled residents (Resident 52) who had a gastrostomy tube (GT, a tube inserted through the wall of the abdomen directly into the stomach. It can be used to give drugs and liquids, including liquid food, to the patient). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store and label medications in accordance with manufacture guidelines for the following: 1. One opened Budesonide inhalation suspension foil pack (medication used to reduce breathing problems) for Resident 152 2. Four Intravenous (IV - administered thorugh a blood vessel) Lorazepam (sedative medication used to treat anxiety or seizures) vials for Resident 87 3. One IV Torbramycin (antibiotic) bag for Resident 1 4. One opened Ipratopium Bromide foil pack (medication used to treat breathing problems) for Resident 72 5. One opened Tuberculin Purified Protein Derivative (PPD-used in the 2-step process to screen new resident for tuberculosis [TB-an infectious disease that primarily affects the lungs] solution multi-dose vial. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Physical Therapy Joint Mobility Screenings (PT JMS, a brief assessment of a resident's range of motion of both legs completed by a Physical Therapist [PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function]), dated 8/19/2024 and 10/15/2024, for one of seven sampled residents (Resident 19) were accurately completed and documented. This deficient practice had the potential to negatively impact the provision of necessary care and services, portray an inaccurate reflection of assessment results, cause miscommunication among staff, and result in missed opportunities to detect declines in joint range of motion (ROM, full movement potential of a joint).

Inspectors wroteBased on interview and record review, the facility's Quality Assessment and Assurance committee ([QAA] a group of facility staff who identifies, evaluates, and implements measures to improve the quality care and life for the residents in the facility) and Quality Assurance Performance Improvement ([QAPI] a group who takes a systemic, interdisciplinary, comprehensive, and data driven approach to maintaining and improving safety and quality in nursing homes while involving residents and families, and all nursing home caregivers in practical and creative problem solving) committee failed to identify concerns related to cardio-pulmonary resuscitation (CPR, it can help save a life during cardiac arrest, when the heart stops beating or beats too ineffectively to circulate blood to the brain and other vital organs) and weight loss in the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to observe infection control measures on 5 of 37 sampled residents (Resident 19, 87,343,16) by failing to: 1. Ensure Restorative Nursing Aide 2 (RNA 2) wore an isolation gown (protective apparel used to protect the wearer from the transfer of microorganisms and body fluids) while providing range of motion (ROM, full movement potential of a joint) exercises to Resident 19 who was on Enhanced Barrier Precautions (EBP, infection control intervention using gown and gloves during high contact resident care activities designed to reduce the transmission of multi-drug resistant organisms). 2. Ensure padded side rails (a padded side fitted to a bed for safety) were not wrapped with foam and paper tape for one of 10 sampled residents (Resident 87). 3. Ensure Resident 343 had an Enhanced Barrier Precaution (EBP: [...]

Inspectors wroteBased on interview and record review, the facility failed to implement the antibiotic stewardship program policy when the antibiotic (a substance used to kill bacteria and to treat infections) did not meet Loeb's or McGeer's Criteria (criteria used to determine appropriate use of antibiotics) for two of three sampled residents: 1. Resident 154 for ceftriaxone (antibiotic used to treat bacterial infections) 2. Resident 29 for cephalexin (another antibiotic used to treat bacterial infections). These deficient practices had the potential to increase antibiotic resistance and provide antibiotics without justification.

Inspectors wroteBased on observation, interview, and record review, The facility failed to respect dignity for one of two residents (Resident 119) who were under hospice care by not providing oral care when resident 119's teeth covered with brown, sticky matters. This failure has the potential to result in aspiration, tooth decay, pain, and infection, compromising Resident 119's comfort, dignity and overall health.

Inspectors wroteBased on interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being for one of three sampled residents (Resident 55) by failing to: 1. Follow the facility policy and procedure to monitor and document assessments and interventions provided to Resident 55 during change of condition (COC). 2. Not creating and implementing a patient centered care plan for actual weight loss. 3. Assess Resident 55's continued weight loss. These deficient practices resulted in Resident 55 requiring a gastrostomy (g-tube: a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) to prevent further weight loss.

Inspectors wroteBased on interview and record review, the facility failed to ensure one out of three sampled residents (Resident 188) had an adequate diagnosis and did not receive unnecessary antipsychotic (altering brain chemistry to help reduce psychotic symptoms like hallucinations, delusions and disordered thinking) medications. This deficient practice placed Resident 188 at risk for harmful side effects of antipsychotic medication including sedation (a decrease in awareness and a decrease in response to external stimulation), drowsiness (sleepy), dizziness, weakness, problems with movement, and changes in weight.

Inspectors wroteBased on interview and record review the facility failed to follow their policy and procedure (P/P) titled Antipsychotic Medication Use by failing to ensure one out of eight sampled residents (Resident 184) had complete physicians orders for psychotropic medications (any drug that affects behavior, mood, thoughts, or perception) including a specific diagnosis. This deficient practice placed Resident 184 at risk for receiving unnecessary medications (medications without adequate indication for use).

Inspectors wroteBased on interview and record review the facility failed to ensure the registered dietician (RD) was competent regarding assessment and reassessment of residents with severe weight loss for one of ten sampled residents (Resident 188), and the RD failed to attend interdisciplinary (an approach to healthcare that integrates multiple disciplines through collaboration) team meetings at the facility. This deficient practice had the potential to cause continued weight loss for Resident 188. Resident 188 had severe weight loss (a weight loss greater than 5% in one month, greater than 7.5% in 3 months, and greater than 10% in 6 months) of 25.8 lbs. or 21.6% in 60 days since admission on [DATE]. This deficient practice placed all 181 Residents at risk for weight loss. Cross reference:

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure, cleaning products used by housekeeping staff were effective against Candida auris ([C. auris] a fungus that can cause severe, often multidrug-resistant infections). This deficient practice resulted the facility's use of an ineffective cleaning agent against C. auris during the facility's ongoing C. auris outbreak (two or more linked cases of the same illness). This deficient practice had the potential for C. auris to survive on surfaces in the facility and spread to other residents.

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement a care plan and/develop a care plan based on an accurate assessment of for one of three residents (Resident 1) after Resident 1 was found sitting on the floor and following Resident 1's fall and fracture (break of the bone) to his nose. These deficient practices resulted in Resident 1's care needs not being addressed and/or addressed inaccurately and had the potential to result in a delay of care. Findings During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and schizoaffective disorder (a mental illness which affects a person's mood and behavior). [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure Psychiatrist Evaluation Progress notes and General Acute Care Hospital (GACH) records were available in the clinical record for one of three sampled residents (Resident 1). This deficient practice resulted in Resident 1's clinical records being incomplete and had the potential for non-continuity of care. Findings During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and schizoaffective disorder (a mental illness which affects a person's mood and behavior). [...]

Inspectors wroteBased on interview and record review, the facility failed to include one of three residents (Resident 1) and/or his Responsible Party (RP 1) in an Interdisciplinary Team ([IDT] a group of professionals with different areas of expertise who work together to achieve a common goal or meet the needs of a resident) Conference when Resident 1 was found sitting on the floor on 7/1/2024. This deficient practice resulted in RP 1 not being aware of Resident 1's change of condition (COC) or their ability to provide input regarding Resident 1's care. This deficient practice had the potential for Resident 1's care needs to go unmet. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement their Covid-19 (highly contagious respiratory infection) policy by failing to conduct contact tracing testing (testing those who were close contacts [sharing the same indoor airspace for a cumulative total of 15 minutes or more over a 24-hour period ]on exposed staff for Covid-19 when four of four residents (Resident 2) tested positive for COVID-19 on 5/21/2024 and 5/22/2024. These deficient practices had the potential to result in undiagnosed or delayed diagnosis of Covid-19 within the facility which does not mitigate the spread of Covid-19 in the facility. Findings During a review of Resident 2's admission Record, the record indicated Resident 2 was admitted on [DATE] with the diagnoses including dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). [...]

Inspectors wroteBased on interview and record review, the facility failed to follow up on missed laboratory (lab) tests for one of three sampled residents (Resident 1) when Resident 1 had lab tests ordered on 5/6/2024 but were not collected by the lab. This deficient practice placed Resident 1 at risk for undiagnosed medical problems due to the lack of monitoring lab test values. Findings During a review of Resident 1's admission Record, the record indicated Resident 1 was admitted on [DATE] with the diagnosis including schizoaffective disorder (a mental health condition where resident has a different perception or reality). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the gastrostomy tube ([GT] a tube which is inserted through the wall of the abdomen directly into the stomach to give medications, fluid, and liquid food to a patient) dressing (woven cotton fabric used to provide a protective barrier between the GT site and the skin which helps prevent maceration [a softening and breaking down of skin resulting from prolonged exposure to moisture]) was replaced when it fell off for two of three sampled residents (Resident's 1 and 2). These deficient practices resulted in Resident's 1 and 2's dressing not being on the GT site, to protect the skin, as ordered and had the potential for Resident's 1 and 2 to have a decline in skin integrity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident, who had no impairments in the right hand and arm range of motion ([ROM], full movement potential of a joint [where two bones meet]) did not acquire an avoidable decline (reduction) in ROM and did not develop a contracture (loss of motion associated with stiffness and joint deformity) of the right wrist and right hand for one of seven sampled residents (Resident 59). The facility failed to: 1. Accurately assess and code the Minimum Data Set ([MDS], a comprehensive assessment and care screening tool) dated 12/28/2023, to indicate ROM limitations in Resident 59's right arm. 2. Assess Resident 59's ROM of both arms for any changes or decline in ROM on the quarterly Joint Mobility Screens ([JMS] a brief assessment of a resident's ROM in both arms and both legs), dated 11/21/2023 and 12/28/2023. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR is guided by federal regulations that require all individuals being considered for admission to a Medicaid-certified nursing facility (NF) level II evaluation was completed for three of five sampled residents (Resident 135,142 and Resident 175) who were diagnosed with mental disorder (MD). This deficient practice had the potential for Resident 135,142 and 175, not receiving appropriate behavioral services.

Inspectors wroteBased on observation and interview, the facility failed to have garbage container in sanitary conditions without lids to cover three (3) outside garbage dumpsters for 179 out of 179 sampled residents. This deficient practice had the potential to harbor and feed pests into the entire facility leading to spread of infectious disease and residents feeling ill.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain respect and dignity on two of four residents (Resident 65 and Resident 142) by CNA standing over the resident while assisting them during a meal. This failure had the potential to result in decreased self-esteem and self-worth on Resident 65 and Resident 142.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 19 and Resident 63) were free of unnecessary physical restraint, as evidenced by: 1. Resident 19 having bilateral upper side rails with two wedge pillows (provides side support, helps to alleviate pressure, and prevent residents from slipping down the bed) underneath the fitted sheets by the leg. 2. Resident 63's bed was against the wall on the right side with bilateral upper side rails on the left side of the bed. These deficient practices placed Resident 19 and 63 at risk for injury and potential for entrapment (event when an individual is trapped or entangles in the spaces of the bed rail). a. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure dietary personnel attended scheduled Interdisciplinary Team meetings ([IDT] a group of professional and direct care staff that have primary responsibility for the development of a plan of care for an individual resident receiving services) for two of eight (8) residents (Residents 34 and 160) who were losing weight in the facility by failing to ensure dietary personnel: 1. Collaborate with various team members during IDT weight loss meetings. 2. Provide effective communication and feedback during IDT meetings to staff members for residents who were losing weight in the facility. 3. Address nutritional needs of the residents during the IDT meeting. [...]

Inspectors wroteBased on observation interview and record review, the facility failed to provide the same regular diet that consisted of diced carrots, red beans and rice, and sliced beef as a pureed diet that consisted of pureed carrots, pureed rice, no red beans, and pureed beef for seven (7) Residents 24, 51, 81, 112, 122, 123, and 131 out of 179 sampled residents. This deficient practice had the potential to result in seven residents not receiving the same week 4 pureed diet as the residents who received a regular diet and not receiving the same calories or nutritional value of their diet ordered per physician order.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, sanitary environment by maintaining proper infection control practices and procedures in the facility by failing to: 1. Ensure residents' clothes were stored in a clean and hygienic (maintaining health and preventing disease, especially by being clean) manner. 2. Ensure boxes were not stored on the floor in the laundry room. 3. Ensure linen and clothes were washed in a safe and sanitized (disinfected) manner. 4. Ensure staffed performed hand hygiene during medication pass for Resident 140. 5. Ensure gloves for resident use were not stored in staff pockets when providing care to Resident 28. 6. Ensure staff performed hand hygiene before and after entering resident's rooms. 7. Ensure staff performed hand hygiene when passing lunch trays. 8. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately assess and code the Minimum Data Set (MDS, a standardized assessment and care-screening tool) assessment for one of seven sampled residents (Resident 59) by failing to ensure the MDS was coded correctly to include impairment of the arm on one side of the body for functional limitations in range of motion ( limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury). This deficient practice had the potential to result in delayed or missed identification of joint range of motion (ROM, full movement potential of a joint) changes, inaccurate care planning, and inadequate provision of services and treatments for Resident 59.

Inspectors wroteBased on observation, interview, and record review, the facility failed to initiate a comprehensive person-centered care plan when the physical restraint hand mitten was implemented on 8/18/2023 for Resident 111 who had a hand mitten on right hand. This deficient practice had the potential for the staff not knowing how to care for residents with a physical restraint and Resident 111 sustaining an injury from the hand mitten physical restraint.

Inspectors wroteBased on interview and record review, the facility failed to review and revise the comprehensive care plan for four of seven sampled residents (Residents 59, 112, 124, and 140) by failing to ensure the following: a. For Resident 59, the facility failed to update the care plan to remove the intervention for a Restorative Nursing Aide program (RNA program, nursing aide program that uses restorative nursing aides [RNA] to help residents maintain their function and joint mobility) for range of motion (ROM, full movement potential of a joint) exercises for the right arm and right-hand splint (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) application when the RNA order was discontinued. b. For Resident 112, the facility failed to update the care plan interventions to: 1. Include an RNA program for ROM exercises to both legs. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the licensed nursing staff failed to follow professional standards of practice for one of one sampled resident (Resident 140) by: 1. Not flushing (act of cleaning) the medication pre and post administering medication through a gastrostomy (g-tube: surgical opening made into the stomach to provide nutritional support). 2. Mixing each medication using the syringe. These deficient practices have the potential to cause additional health complications such as dislodgement of g-tube or the resident not receiving all the necessary doses for the medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 107) was provided an alternate means to communicate with a language that the resident was able to understand. This deficient practice had the potential to place Resident 107 at risk for feeling of frustration, isolation, and not able to communicate with the staff his needs which could lead to a delay on receiving appropriate care and services.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure wheelchair bound (unable to walk) resident get up in bed to attend out of the room group activities for one of nine sampled residents (Resident 29) for 60 days. This failure resulted in Resident 29 unable to attend activities of her choice and had the potential to cause psychosocial harm, like depression (feeling of sadness) and feeling of isolation.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sample residents (Resident 65) was properly positioned in the bed during meal assistance. This deficient practice had the potential to place Resident 65 at risk for choking and aspiration (when food, liquid, or other material enters a person's airway and eventually the lungs by accident which could result to serious health issues like pneumonia, infection in the lungs).

Inspectors wroteBased on observation, interview, and record review, the facility failed to secure a medication in a locked storage area for one of eight (8) residents (Resident 59) by leaving a Protonix (treats heartburn, stomach ulcers, reflux disease, or other conditions that cause too much stomach acid) 40 milligrams ([mg] unit of measurement) before breakfast daily at Resident 59's bedside unattended, This deficient practice placed Resident 59 at risk for medication errors and had the potential for unsafe medication administration to other residents, staff, or visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow one of two (Resident 149) sampled resident's allergy preference, resulting in Resident 149 receiving chocolate shake when Resident 149 is allergic to chocolate. This deficient practice had the potential to cause an allergic reaction that could have been detrimental to the resident's well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. A bowl of ground beef was stored on the second shelf from top shelf and a bag of cabbage and bag of broccoli was stored below the raw ground meat. 2. A bowl of sliced sausage on the second shelf and a bowl of onions on the same shelf. 3. A bowl of onions and cabbage stored on the third shelf below the diced sausage in the walk-in refrigerator for 179 out of 179 sampled residents. 4. Dietary cook carried a bowl of sliced sausage covered with plastic stack on top of a bowl of onions while bringing it to the stove area. 5. One box of beans was stored without covering in the dry food storage area. [...]

Inspectors wroteBased on interview and record review, the facility's Quality Assessment and Assurance ([QAA] to develop and implement appropriate plans of action to correct identified quality deficiencies) and Quality Assurance Performance Improvement ([QAPI] designated to bring about constant and measurable improvement in the services provided at the facility for continual improvement of quality care) committee failed to: 1. Maintain effective systems in place to obtain and use feedback for facility issues submitted by direct care staff, residents, and resident representatives. 2. Monitor, review and analyze data for performance improvement of facility issues such as falls, call lights, Infection Control, and weight loss. 3. Failing to have a QAPI committee meeting December 2023. These deficient practices have the potential to not identify systematic approach to improve services to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their infection prevention and control program (IPCP) during a Norovirus (contagious virus that spread through touching and eating contaminated surfaces and food and causes vomiting and diarrhea (watery stool) outbreak (OB: sudden increase in occurrences of a disease) by: 1. Not having the contact precaution (procedure used to reduce the spread of infections through direct or indirect contact) signage in front of the isolation rooms. 2. Certified NUrse Assistant (CNA) 1, CNA 2, CNA 3, and CNA 4 not performing hand hygiene before entering and exiting the isolation rooms. These deficient practices resulted in 15 residents and two staff members who exhibits signs and symptoms of Norovirus and two residents (Resident 1 and Resident 7) tested positive.

Inspectors wroteBased on observation, interview and record review, the facility staff failed to ensure staffnot wearing an isolation gown while walking in the hallway. This deficient practice had the potential to spread infection throughout the facility.

Inspectors wroteBased on interview and record review the facility failed to report the Coronavirus disease ([Covid-19] a very contagious infectious disease) outbreak (at least one resident is confirmed positive with Covid-19), with four residents positive for Covid-19 (Resident 6,7,8,9) out of one hundred eighty six (186) total residents, to the California Department of Public Health (CDPH) Licensing and Certification (L&C), within twenty four hours of the start of the outbreak on 10/10/2023. This deficient practice resulted in a delay of the CDPH investigation and potentially increased the risk of further spreading Covid-19 to other residents and staff.