Colonial Gardens Nursing Home

Inspectors wroteBased on interview and record review, the facility failed to ensure a comprehensive care plan was revised for one of four sampled residents (Resident 3), following a second episode of aggression. This deficient practice had the potential to place Resident 3 at risk for further episodes of physical and verbal aggression toward staff and residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate and complete documentation of monitoring of a resident's aggressive behaviors following readmission from a 5150 hold (a 72-hour hold for a resident experiencing a mental health crisis and evaluated to be a danger to others, themselves, or gravely disabled) at the general acute care hospital (GACH) and a physical altercation for one out of five sampled residents (Resident 1). This deficient practice had the potential to place Resident 1 and other residents at risk for physical harm caused by Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to report an injury of unknown origin to the California Department of Public Health (CDPH) for one of three sampled residents (Resident 3). This deficient practice resulted in delayed investigation by CDPH and had the potential to place residents safety at risk.

Inspectors wroteBased on interview and record review, the facility failed to ensure fall risk assessments accurately reflected residents' status and was updated following a fall for one of three sampled residents (Resident 3). These deficient practices had the potential to place Resident 3 at an increased risk for a fall.

Inspectors wroteBased on interview and record review, the facility failed to follow the care plan and monitor for paranoid delusions (fixed, irrational beliefs that others are plotting against or trying to harm you, without evidence) for one of three sampled residents (Resident 1). This deficient practice had the potential to result in unmonitored paranoid delusions and unaddressed aggressive behaviors.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five residents (Resident 1), received treatment and care in accordance with professional standards of practice. The facility failed to: 1). Ensure Resident 1's Medical Doctor (MD) was notified of the resident's refusal to eat breakfast and lunch, during the resident's change of condition (COC) on 12/18/2025.2). Carry out (follow) MD's urinalysis ([UA] a common diagnostic test that examines the urine to detect disorders) order on 12/18/2025.3). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a care plan addressing a resident's diagnosis of sleep apnea (blocked airways) and use of a Bilevel Positive Airway Pressure ([BiPAP] a breathing therapy used to help a person with breathing difficulties) for one out of three sampled residents (Resident 2). These deficient practices had the potential to place Resident 2 at risk for device related injury, respiratory distress, and not receiving the necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the safe storage of medications for one of three sampled residents (Resident 2). This deficient practice had the potential to place Resident 2 at risk for unsafe medication administration, misuse of medications and overdose.

Inspectors wroteBased on interview, and record review, the facility failed to ensure Certified Nurse Assistant (CNA 1) had the competencies and skill sets necessary to immediately provide Basic Life Support ([BLS] medical care for residents experiencing cardiac arrest [when the heart stops beating] or respiratory distress [difficulty in breathing]) for one of three sampled residents (Resident 3), who had a full code status (when a medical personnel does everything possible to save a person's life in a medical emergency), was observed unresponsive in bed. This deficient practice had the potential for delayed provision of BLS for Resident 3 and other residents at risk of not receiving timely life saving measures.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe, home-like environment for one of three sampled residents (Resident 2) by failing to replace the broken window in Resident 2's room in a timely manner. This failure had the potential to result in Resident 2 feeling uncomfortable due to cold air coming inside the window and negatively affecting Resident 2's well-being.

Inspectors wroteBased on interview and record review, the facility failed to inform Physician 1 and Conservator 1 of an abuse allegation for one of three sampled residents (Resident 5). This deficient practice resulted in a delay in potential medical and psychiatric evaluations and resulted in Conservator 1 being unaware of Resident 5's well-being.

Inspectors wroteBased on interview and record review, the facility failed to report an abuse allegation to the State Agency (California Department of Public Health [CDPH]), the ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), and local law enforcement for one of three sampled residents (Resident 5). This deficient practice resulted in a delayed notification to CDPH, the ombudsman, and law enforcement and also resulted in a delay of an onsite inspection This deficient practice had the potential to result in potential abuse to all residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to develop a person-centered care plan for one of three sampled residents' (Resident 5) after Resident 5 informed Licensed Vocational Nurse (LVN) 11 of an abuse allegation. This deficient practice had the potential to negatively affect Resident 5's physical, mental, and psychosocial well-being, delay the delivery of necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to implement the Care Plan for one out of five sampled residents (Resident 2), who had a diagnosis of schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) and exhibited increased in behaviors. This failure had the potential to result in Resident 2 having ongoing behaviors which could lead to altercations that endanger himself, other residents, and staff at the facility. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 2's diagnoses included schizoaffective disorder. [...]

Inspectors wroteThis is a Repeat Deficiency at F609 from 6/24/2025 investigation. Based on interview and record review, the facility failed to report abuse allegations to the State Agency (California Department of Public Health [CDPH]), the ombudsman (an advocate for residents of nursing homes), and local law enforcement for three of seven sampled residents (Residents 5, 6, and 7) when Certified Nursing Assistant (CNA) 5 allegedly was rough with Residents 5, 6 and 7. This repeat deficient practice of delayed notification to CDPH, the ombudsman, and law enforcement resulted in a delay of an onsite inspection and had the potential to result in abuse to all residents in the facility. [...]

Inspectors wroteThis is a Repeat Deficiency at F610 from 6/24/2025 investigation. Based on interview and record review, the facility failed to thoroughly investigate an allegation of abuse for one of seven sampled residents (Resident 7), when Resident 7 informed Social Services (SS) 1, on 7/22/2025, that Certified Nursing Assistant (CNA) 5 was rough during facial shaving. This deficient practice resulted in CNA 5 not being suspended pending the investigation of the allegation and placed Resident 7 and all the residents in the facility at risk for further potential abuse. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of seven sampled resident (Resident 4's) care plan was reviewed and revised with updated interventions to address Resident 4's behavior of pocketing medications. This deficient practice resulted in Resident 4 having medication in his possession without staff knowledge and an increased risk for adverse medication reactions. Cross Reference F755.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered to meet the needs of each resident and in accordance with professional standards of practice for one of seven sampled residents (Resident 4). Resident 4 was observed with two medications in hand, without staff knowledge. This deficient practice resulted in Resident 4 not receiving the correct dose of medication, and the potential for other residents to receive medications not prescribed to them. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) Committee / Quality Assessment and Assurance (QAA) implemented action plans to correct previously identified abuse allegation deficiencies from June 2025. This repeat deficient practice caused an increased risk in the safety and dignity of the residents of the facility.

Inspectors wroteBased on interview and record review, the facility failed to inform one of three sampled residents' (Resident 1) physician of the resident's Responsible Party's (RP 1) decision to not have a Computed Tomography (CT- a medical imaging procedure to create detailed images of the head) done after Resident 1 was found to have discoloration on his forehead. This deficient practice resulted in Physician 1 being unaware of RP 1's decision which resulted in no further ordered interventions.

Inspectors wroteBased on interview and record review, the facility failed to report an injury of unknown origin to the State Agency (California Department of Public Health [CDPH]), the ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), and local law enforcement for one of three sampled residents (Resident 1) when Resident 1 was found to have discoloration on the right side of his forehead. This deficient practice of delayed notification to CDPH, the ombudsman, and law enforcement resulted in a delay of an onsite inspection. This deficient practice had the potential to result in further injury to Resident 1. Cross Reference F610.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate an injury of unknown origin for one of three sampled residents (Resident 1) when Resident 1 was found to have discoloration on the right side of his forehead. This deficient practice resulted in the facility being unaware of the cause of Resident 1's injury. Cross Reference F609.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free of accidents and hazards after falling on 4/10/2025 by failing to: 1. Complete Resident 1's 72-Hour Neurological Check (Neuro Check- series of tests over a 72-hour period to assess for changes in neurological function). 2. Complete Resident 1's post-fall Fall Risk Assessment. 3. Compete the documentation for the Interdisciplinary Team (IDT, a group of healthcare professionals with various areas of expertise who work together towards the goals of the residents) meeting on 4/11/2025. These deficient practices had the potential to result in Resident 1 sustaining undetected neurological changes which could have resulted in delay in treatment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Remove one bottle of expired cetirizine hydrochloride (medication to relieve allergy symptoms) 5 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount) inside one of two inspected medication carts (Main St Medication Cart). 2. Remove one bottle of expired haloperidol decanoate (antipsychotic medication [to treat psychosis- a severe mental illness where individuals experienced a distorted perception of reality) in one of two inspected medication rooms (Medication Room Nursing Station 2). [...]

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. Two containers that contained personal food were stored inside Refrigerator 1. 2. One opened bottle of chocolate syrup, one opened bottle of caramel drizzle, one opened can of whipped cream and one container of white chopped onions were stored and unlabeled in the walk-in refrigerator. 3. One opened carton of ice cream was stored in the walk-in freezer unlabeled. These failures had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 95 of 99 medically compromised residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the safe medications administrations for two of six residents (Resident 17 and Resident 76) when the following occurred: 1. 40 out of 40 doses of oyster shell calcium (a dietary supplement) 500 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount) were not administered to Resident 17 from 5/1/2025 to 5/20/2025. 2 a. Two out of 38 doses of tramadol HCl (a strong painkiller from a group of medicines called opiates, or narcotics) 50mg for Resident 76 on North Station, North Medication Cart on 5/21/2025 were not accurately accounted for and documented. b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that resident bedrooms accommodated no more than four residents in four of 42 bedrooms (Rooms A, B, C, and D). This deficient practice could adversely affect the adequacy of space, nursing care, comfort, and privacy to the residents and their visitors residing in Rooms A, B, C, and D.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure choices were honored for one of three residents (Resident 74) when the resident was not permitted to take requested smoke breaks. This failure interfered with Resident 74's right to make choices about his routine and preferences.

Inspectors wroteBased on interview and record review, the facility failed to obtain informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) from the residents prior to treatment of psychotropic (medications that affect brain activities associated with mental processed and behavior) medications for two of six sampled residents (Residents 40, and 64) by failing to: 1. Obtain informed consent from Resident 40, for the use of Quetiapine Fumarate (an antipsychotic medication [a medication that effects the mind, emotion, and behavior]). 2. Ensure Resident 64's informed consent for Depakote (an anticonvulsant medication used to treat behavioral disorders), Risperdal (an antipsychotic medication), and Seroquel (an antipsychotic medication) were complete. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a call light device was within reach for one of eight sampled residents (Resident 47). This deficient practice resulted in Resident 47 being unable to summon staff for assistance in a timely manner and had the potential to compromise Resident 47's safety and care.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) and one of two residents (Resident 98) was provided a notice of discharge prior to the resident's discharge on [DATE]. This deficient practice increased the risk of potential harm to Resident 98 and breach of the resident's rights.

Inspectors wroteBased on interview and record review, the facility failed to complete the Minimum Data Set (MDS - a federally mandated resident assessment tool) for significant change in status within the required time frame for one of six sample residents (Resident 40). This failure had the potential to negatively affect Resident 40 receiving the necessary care services that would have been required due to their significant change in status.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete the minimum data set (MDS - a comprehensive resident assessment tool) assessment Section I (active diagnoses) by failing to include a diagnosis of depression (a mental disorder characterized by depressed mood, poor appetite, difficulty sleeping, and lack of interest in normal enjoyable activities) per information in the medical record for one of six sampled residents (Resident 54). The deficient practice of failing to accurately assess active diagnoses and complete MDS Section I increased the risk that Resident 54 may not have received care planning and treatment according to his needs possibly leading to a decline in his overall health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure the following for three of 12 sampled residents (Resident 17, 54, and 61): 1. Develop and implement a care plan for Resident 17's diagnosis of vitamin D deficiency (low levels of vitamin D in the body), and the administration of oyster shell calcium (a dietary supplement), Trazodone (a medication used to treat depression [mental health disorder]), and Buspirone (a medication used to treat anxiety [a feeling fear, and worry]). 2. Develop and implement a care plan addressing Resident 54's diagnosis of depression. 3. Implement Resident 61's care plan addressing the resident's oxygen therapy and diagnosis of chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide safe enteral nutrition (the delivery of liquid nutrients through a feeding tube directly into the gastrointestinal tract) for one of six sampled residents (Resident 40), when Resident 40's head of bed was not maintained in an elevated 30 to 45 degrees (refers to an angle of position) position while receiving enteral nutrition by gastrostomy tube (GT - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). This failure had the potential for resident harm and or death, as the provision of enteral feedings without elevating Resident 40's resting position increased the risk for vomiting and aspiration pneumonia, which may be caused when liquid nutrition and/or other stomach contents enter a person's airway and/or lungs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care was provided according to physician's orders and professional standards of practice for one of three residents reviewed for oxygen therapy (Resident 61) when the following occurred: 1. Staff administered continuous oxygen at a rate of 4.5 liters per minute (LPM- a unit of measurement), exceeding the prescribed rate of two liters per minute as needed. 2. Resident 61 was observed unmonitored in the facility patio with increased respirations without his supplemental oxygen. 3. Staff failed to ensure the amount of oxygen administered to Resident 61 was documented from 4/29/2025 to 5/20/2025. These failures had the potential to place Resident 61 at risk for oxygen toxicity (lung damage from too much extra oxygen) and respiratory distress, and compromise Resident 61's safety.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were monitored for medication side effects or efficacy of medication for two of 12 sampled residents (Residents 17 and 29), by failing to: 1. Monitor signs and symptoms of bleeding for Resident 17, who was receiving Eliquis (an anticoagulant medication, used to prevent blood clots forming in the blood vessels and the heart). 2. Monitor Resident 17's sleep hours, who was receiving Trazadone (a medication used to treat depression [-a mental health disorder], and insomnia [-a sleep disorder]). 3. Monitor Resident 17's episodes of physical restlessness (behaviors such as agitation, inability to sit still) constantly trying to get up unassisted, who was receiving Buspar (a medication used to treat anxiety [-a feeling fear, and worry]). 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure physician ordered therapeutic diets were provided for one of six sampled residents (Resident 90), when Resident 90 did not receive their Magic Cup (a frozen dessert used for providing additional calories and protein to those experiencing involuntary weight loss). This failure could have resulted in insufficient food intake, unintentional weight loss, and a deterioration of Resident 90's overall health condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection (the invasion and multiplication of microorganisms [like bacteria, viruses, etc.] in body tissues, potentially causing illness or harm) control practices for one of six residents (Resident 40) when Resident 40's urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) drainage bag was observed touching the floor on 5/20/2025. This deficient practice placed Resident 40 at risk for infection which could increase the resident's and other residents morbidity (the amount of disease in a population) and mortality (the state of being subject to death).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call system was functional for two of eight sampled residents (Resident 47 and Resident 78). This deficient practice resulted in Resident 47 being unable to summon staff for assistance in a timely manner and had the potential to result in Resident 47's and Resident 78's needs to go unmet and compromise the residents' safety and cause bodily injury from a fall.

Inspectors wroteBased on interview and record review, the facility failed to meet the required room size measurement of 80 square feet per resident in rooms with multiple residents. This deficient practice had the potential for inadequate space for each resident's privacy and unsafe nursing care.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure a seven-day bed hold was maintained for two of two sampled residents (Resident 1 and Resident 3) after they were transferred to the General Acute Care Hospital (GACH). This deficient practice resulted in the resident ' s rights being violated by not allowing them to return to their assigned beds in the facility per State and Federal regulations.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safety was maintained for one of four sampled residents (Resident 3), by not ensuring her call light was maintained within reach. This deficient practice placed Resident 3 at risk for harm and injury related to a fall.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive, resident-centered care plan, with interventions, after the two episodes of choking (when airway is blocked by a foreign object, such as food, preventing oxygen from reaching the lungs, leading to a life-threatening situation) on 1/6/2025 and 1/15/2025 for one of five residents (Resident 2). The facility failed to provide interventions for staff to implement at dinner time for Resident 2 ' s safety. These failures left Resident 2 unsupervised during dinnertime and had potentially caused Resident 2 to aspirate (when food, liquid, or other substances entered the airway and the lungs) on 3/5/2025 and other complications such as, choking, loss of consciousness (state of being awake and aware of one ' s surroundings), apnea (not breathing) and death.

Inspectors wroteBased on interview and record review, the facility failed to reassess the respiratory status on one of five residents ' (Resident 2), who had an oxygen saturation of 86% ([O2 sat] amount of oxygen in the blood- normal range 95 per cent (%)-100%) on 3/5/2025 at 5:28 p.m. As a result of this failure, Resident 2 ' s respiratory status worsened and potentially contributed to the resident ' s loss of consciousness (pass out), apnea (not breathing) and death.

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision to one of five residents (Resident 2), after the two choking (when airway is blocked by a foreign object, such as food, preventing oxygen from reaching the lungs, leading to a life-threatening situation) incidents on 1/6/2025 and 1/15/2025. This failure left Resident 2 unsupervised while eating dinner on 3/5/2025, and had potentially caused Resident 2 to aspirate (when food, liquid, or other substances entered the airway and the lungs) and caused other complications such as, choking, loss of consciousness (state of being awake and aware of one ' s surroundings), apnea (not breathing) and death.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five residents (Resident 1), who was admitted to the facility with Carbapenem-Resistant Enterobacterales ([CRE], a group of bacteria resistant to carbapenem [an antibiotic]), was placed on contact precautions (measures that are intended to prevent transmission of infectious agent which are spread by direct or indirect contact with the resident or the resident's environment). This failure had the potential to spread the organisms to other residents and staff and can potentially cause infections.

Inspectors wroteBased on interview and record review, the facility failed to follow an infection prevention and control program for scabies (a contagious skin condition caused by tiny insects called mites that infest and irritate skin causing intense itching, inflammation, and red patches) for six out of six sampled residents (Resident 1, 2, 3, 4, 5, and 6) by failing to: 1. Place Residents 1, 2, 3, 4, 5, and 6 on Contact Precautions (refer to measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident ' s environment) immediately. Resident 1 was diagnosed with scabies in the general acute care hospital (GACH) and returned to the facility on [DATE]. Resident 1, 2, 3, 4, 5, and 6 was placed on Contact Precautions on 11/5/2024, 2 days after Resident 1 returned to the facility. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Assess the elopement (to leave unnoticed) risk for one of two sampled residents (Resident 1) who attempted to elope from the facility on 4/30/2024 and 5/23/2024 and was assessed on the Minimum Data Set (MDS, resident assessment and care-screening tool) as having wandering behaviors (when a person leaves a safe area or caregiver, which can be a risk to their safety, also called elopement), per the care plan. 2. Follow its policy and procedures (P&P) titled Interdisciplinary Team Conference (IDT, group of different disciplines working together towards a common goal for a resident) and Elopement Wandering Resident by not holding an IDT meeting to ensure resident ' s safety, after Resident 1 ' s elopement attempts on 4/30/2024 and 5/23/2024. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the Resident 1 ' s responsible party (RP 1), Resident 2, and Resident 2 ' s responsible party (RP 2) of their rights to participate in the resident care conference to discuss the plans of care and discharge goals for two of two sampled residents (Resident 1 and Resident 2). This deficient practice violated RP 1, Resident 2, and RP 2 ' s rights to be active participants in their care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the physician for one of two sampled residents (Resident 1) following Resident 1 sustaining a five (5) pound (lb., unit of measurement) weight loss between May 2024 and June 2024, and again following a nine (9) lb. weight loss between May 2024 and August 2024. This deficient practice placed Resident 1 at risk for delayed intervention and care plan adjustments, possibly resulting in further avoidable unplanned weight loss and not meeting her nutritional needs.

Inspectors wroteBased on interview and record review, the facility failed to revise the nutritional care plan for one of two sampled residents (Resident 1) following Resident 1's five (5) pound (lb., unit of measurement) weight loss between May 2024 and June 2024, and again following a nine (9) lb. weight loss between May 2024 and August 2024. This deficient practice placed Resident 1 at risk for not receiving the required interventions to prevent further avoidable unplanned weight loss and inability to meet her nutritional needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1) was referred to the facility ' s Nutrition Weight Variance Committee following a five (5) pound (lb., unit of measurement) weight loss between May 2024 and June 2024, and again following a nine (9) lb. weight loss between May 2024 and August 2024. This deficient practice resulted in Resident 1 sustaining an additional one (1) lb. weight loss in August 2024, and placed her at increased the risk sustaining further avoidable unplanned weight loss and not meeting her nutritional needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor for aggressive behaviors for one out of three residents (Resident 2) after the resident had consecutive and ongoing refusals of Zyprexa (an antipsychotic medication used to treat mental health conditions) for angry outbursts. This deficient practice had the potential to exacerbate Resident 2's aggression and cause harm to Resident 1.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe and sanitary food storage practices in the kitchen that placed 99 out of 99 sampled residents at risk for food borne illness (an illness that comes from eating contaminated food) when the facility failed to ensure: 1. The walk -in refrigerator contained food with no in date (the date when the food was placed in the refrigerator) and no use by date (date the food item must be consumed by). 2. The walk-in refrigerator contained expired food. 3. The walk-in freezer had food items that was not labeled with in date and a use by date. 4. The dry storage room had food bins that were not labeled with an in date and a use by date. 5. The Kitchen staff did not ensure thawing meat was placed on the lowest shelf in the refrigerator. 6. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an effective and comprehensive Quality Assurance Performance Improvement (QAPI) program was implemented and maintained for all 99 residents by not performing the following: 1. Ensure that the Infection Prevention Nurse (IPN) was a participant in the facility's QAPI meetings. 2. Ensure a method tracking and monitoring of measurable outcomes were in implemented to record the progress of each QAPI action plan. This deficient practice had the potential to negatively impact patient care, safety, and satisfaction, and to allow facility-identified patient care issues or concerns to reoccur within the facility. Cross reference F867.

Inspectors wroteBased on interview and record review, the facility's Quality Assessment and Assurance Committee (QAA) failed to implement measures to effectively collect and use data to monitor the effectiveness of Quality Assurance Plan Improvement (QAPI) plans and track overall performance for all 99 residents. This deficient practice had the potential to negatively impact resident care, safety, and satisfaction, and had the potential to allow facility-identified resident care issues or concerns to reoccur within the facility. Cross reference F865.

Inspectors wroteBased on interview and record review, the facility failed to implement an effective infection prevention control program for all residents by failing to maintain and complete the infection surveillance documentation. This deficient practice had the potential to cause the spread of infection causing organisms amongst all staff and/or residents.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete antibiotic stewardship documentation for the facility for June 2024. This deficient practice had the potential for residents to be administered and prescribed antibiotics (medication to treat infections) inappropriately and unnecessarily.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Obtain informed consent (process of communication between resident/responsible party and health care provider that often leads to agreement or permission for care, treatment, or services) prior to initiation and administration of psychotropics medications (medications that affect the mind, emotions, and behavior) for two out of eight sampled residents (Resident 6, and Resident 52). 2. Obtain informed consent for a bed alarm and a wheelchair alarm (bed exit alarms that warn caregivers when patients leave or attempt to leave their beds or wheelchairs) for one out of eight sampled residents (Resident 33). 3. Obtain informed consent for one of one sampled resident's (Resident 81) bed bolster (an alternative to side rails that helps prevent residents at risk for falls from rolling out of bed). [...]

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure behaviors of rummaging through other's belongings related to the use of Clozaril (a medication used to treat mental illness) were monitored in the resident's Medication Administration Record (MAR - a resident's record of all medications administered, and monitoring done) between 6/1/2024 and 6/26/2024 in one of five sampled Residents (Resident 6.) 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%). Four medication errors out of 25 total opportunities contributed to an overall medication error rate of 16 % affecting two of eight residents observed for medication administration (Resident 66 and Resident 69.) The medication errors noted were as follows: 1. Omitted one dose of Lactulose (a medication used to treat high levels of ammonia in the blood). 2. Omitted one dose of vitamin C (a supplement). 3. Omitted one dose of vitamin D (a supplement). 4. Omitted one dose of aspirin (a medication used to prevent blood clots). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure two expired insulin (a medication used to control high blood sugar) pens were removed from the medication cart affecting Residents 31 and 148 in one of four inspected medication carts (Station 1 AM Medication Cart). 2. Ensure two unopened insulin pens were stored in the refrigerator according to the manufacturer's requirements affecting residents 14 and 40 in two of four inspected medication carts (Station 1 AM Medication Cart and Station 2 AM Medication Cart). [...]

Inspectors wroteBased on interview and record review, the facility failed to offer and administer the pneumococcal vaccine (medication that trains the body's immune system so that it can fight pneumonia [an infection that inflames the air sacs in one or both lungs]) to four of five sampled residents (Resident 54, 60, 62, and 70), who were eligible to receive the vaccine. This deficient practice had the potential to result in the development and spread of pneumonia.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that resident bedrooms accommodated no more than four residents in four of 32 bedrooms (Rooms A, B, C, D). This deficient practice could adversely affect the adequacy of space, nursing care, comfort, and privacy to the residents and their visitors residing in Rooms A, B, C, and D.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate the needs for one of eight sampled resident's (Resident 66) by: 1. Failing to place the call within reach. 2. Failing to provide an appropriate call light device. These deficient practices prevented Resident 66 from communicating with staff and had a potential to delay and receive appropriate care, treatment, and services when needed for Resident 66.

Inspectors wroteBased on interview and record review, the facility failed to ensure Resident 6, who had impaired cognition for daily decision making, had a representative that acted on behalf of the resident for medical decision-making. This deficient practice placed Resident 6 at risk for all health care decisions, risk and benefits of medications and treatments, and of other available treatment alternatives.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician and responsible party (RP) of an unplanned significant weight loss of 14 pounds (6.6 percent [%] weight loss) for one of five sampled residents (Resident 4). This failure had the potential to place Resident 4 at risk for further weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 81), was free from unnecessary physical restraints (any mechanical or physical material, device, or equipment that is attached to or adjacent to a resident's body that restricts the resident's freedom of movement and cannot be easily removed by the resident) by: 1. Failing to attempt least restrictive measures before implementing a bed bolster (an alternative to side rails that helps prevent residents at risk for falls from rolling out of bed) for Resident 81 while in bed. 2. Failing to provide and document on-going monitoring for Resident 8l while implementing the use of a bed bolster to prevent falls. [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately complete the Minimum Data Set (MDS - a comprehensive resident assessment tool) assessment Section I (active diagnoses) by failing to include accurate diagnoses per information in the medical record for three of five sampled residents Resident 3, 6, and Resident 60) when the facility failed to perform the following: 1. Ensure the accurate diagnosis of depression (a group of conditions associated with the elevation or lowering of a person's mood) for Resident 6 and Resident 60 were documented in the MDS Section I. 2. Ensure the accurate diagnosis of dementia (a group of thinking and social symptoms that interferes with daily functioning with behavioral disturbance) for Resident 3 was documented in the MDS Section I. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement care plans (plans of care specific to a resident) for three out of six sampled residents (Resident 3, 33, and 65) by failing to: 1. Ensure an individualized care plan was developed for Resident 3's diagnosis of dementia (a group of thinking and social symptoms that interferes with daily functioning with behavioral disturbance). 2. Ensure an individualized care plan was developed for Resident 33's diagnosis of anxiety (intense, excessive, and persistent worry and fear about everyday situations). 3. Ensure an individualized care plan was developed for Resident 65's diagnosis of seizure (burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements (stiffness, twitching or limpness), behaviors, sensations, or states of awareness). [...]

Inspectors wroteBased on interview and record review, the facility failed to revise a care plan (document that helps nurses and other team care members organize aspect of resident care) for one of five sampled residents (Resident 4), who had an unplanned significant weight loss of 14 pounds (lbs). This deficient practice had the potential to result in Resident 4 having further weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the policy and procedures for accurate assessment for two out of six sampled residents (Resident 55 and Resident 4) by failing to: 1. Ensure an accurate assessment was performed and documented every shift, as indicated by the Skin Integrity Care Plan, prior to Resident 55's development of bruising to the left chest and torso (the main part of the body that contains the chest, abdomen, pelvis, and back) for Resident 55. 2. Transcribe (copy from one place to another) a physician order of weekly weights and laboratory tests to the Physician Telephone Orders form for Resident 4. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of eight residents (Resident 66) was provided a communication card (a set of icons that patients can use if they are having difficulty communicating their immediate needs, wants or concerns) with the language (Spanish) Resident 66 was able to understand. This deficient practice prevented Resident 66 from communicating effectively with the staff and had the potential to delay and receive appropriate care, treatment, and services for Resident 66.

Inspectors wroteDuring an observation, interview, and record review the facility failed to practice pressure related injury preventive practices (interventions to prevent skin breakdown) for two out of eight residents (Resident 65, and Resident 77) when the facility failed to: 1. Ensure a low air mattress ([LAM], a mattress that provides airflow to help keep skin dry, as well as to relieve pressure, treat pressure sores and prevents pressure sores) was set according to Resident 65's weight of 106 pounds and the LAM was set between 150 pounds to 200 pounds. 2. Ensure the LAM was set according to Resident 77's weight of 135 pounds and LAM was set to 350 pounds. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision and provide an environment free of accidents when the facility failed to ensure the following: 1. Adequate supervision was provided for a resident with a known history of falls and poor safety awareness and fell four times within the month (6/2024) for one out three sampled residents (Resident 16). 2. A cabinet that housed two cleaning solution spray bottles in Hallway A was secured and inaccessible to all residents. These deficient practices had the potential for Resident 16 to sustain bodily injury from another fall and for all residents to be subject to chemical injury if the contents of the cleaning solution were sprayed, ingested (consumed) or used to cause harm to other residents or staff members.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 58) received respiratory care consistent with professional standards of practice when the oxygen nasal cannula tubing (a device used to deliver supplemental oxygen), was not labeled. This deficient practice had the potential to result in unsafe use of oxygen equipment and potentially cause respiratory infection, and/or hospitalization for Resident 58.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from significant medication errors by: 1. Failing to administer one dose of aspirin (a medication used to prevent blood clots) per the physician's order on 6/25/2024 to one of eight residents observed for medication administration (Resident 69). 2. Failing to administer one dose of Lactulose (a medication used to treat high levels of ammonia in the blood) per the physician's order on 6/25/2024 to one of eight residents observed for medication administration (Resident 66). The deficient practice of failing to administer medications in accordance with the physician's orders, including any required time frame, increased the risk that Residents 66 and 69 may have experienced medical complications possibly resulting in hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the kitchen staff served the correct diet for one of one sampled resident (Resident 48) by failing to: 1. To serve a therapeutic regular diet with chopped meat for Resident 48. This deficient practice had the potential for Resident 48 to receive food that was not palatable and may have caused Resident 48 not to eat her food resulting in possible weight loss.

Inspectors wroteBased on interview and record review, the facility failed to retain pneumococcal vaccine (medication that trains the body's immune system so that it can fight pneumonia [an infection that inflames the air sacs in one or both lungs]) administration records indicating the type of vaccine three of five sampled residents (Resident 45, 54, and 70) received. This deficient practice had the potential to result in the inappropriate administration of the pneumococcal vaccine.

Inspectors wroteBased on interview and record review, the facility failed to meet the required room size measurement of 80 square feet per resident in rooms with multiple residents. This deficient practice had the potential for inadequate space for each resident's privacy and unsafe nursing care.

Inspectors wroteBased on interview and record review, the facility failed to establish a comprehensive and person-centered plan of care, for one of three sampled residents (Resident 1) to address Resident 1's medical diagnosis of type 2 diabetes mellitus ([DM]-abnormal blood sugar). This deficient practice resulted in Resident 1 not receiving the interventions for elevated blood sugar levels.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure four (4) of 10 sampled residents (Residents 84, 36, 345, and 80) were free from physical restraints, by not ensuring: 1. Assessments were completed prior to applying the physical restraints. 2. Adequate monitoring and periodic release of the physical restraints to ensure adequate blood circulation and skin integrity. 3. Development and implementation of care plans addressing the use of physical restraints. 4. Least restrictive measures were used prior to the implementation of restraints, per the facility's policy. These deficient practices resulted in the use of unnecessary physical restraints, placing the residents at risk for psychosocial harm from not being treated with respect and dignity; [...]

Inspectors wroteBased on interview and record review, the facility failed to protect the health, welfare, and rights of 93 of 93 residents by failing to: a. Develop a policy that ensured the reporting of all alleged abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) incidents to authorities as required by federal law. b. Screen potential employees for history of abuse, neglect (the failure to provide goods & services necessary to avoid physical harm, mental anguish, or mental illness), exploitation, or misappropriation of resident property (deliberate misplacement or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent) and maintain documentation that screening occurred. These deficient practices placed all 93 residents at high risk for abuse and neglect.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the planned menu items and recipe was followed during meal preparation. This deficient practice had the potential for 90 out of 93 residents to not receive a proper therapeutic diet as ordered.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices were followed in the kitchen when the following was observed: a. A dirty can opener blade attachment was observed. b. [NAME] 1 did not follow standardized recipes when preparing food on 4/4/2022 and was not evaluated for competency related to food preparation. c. Reach-in freezer had several gaps on the temperature logs for the months of February and March 2022. d. Several food items and bulk items were not dated, labeled and sealed after opened in the food preparation area, walk-in freezer and dry storage area. e. Dishwasher 1 (DW 1) and Dietary Aide (DA 1) did not know which sanitizer test strip to use for the dish machine sanitizer and quaternary ammonium ([QUAT] a type of sanitizing solution) sanitizer. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure: a. The facility's training program was implemented to ensure any training needs were met for all new and existing staff. b. The facility's evaluation of policies and procedure were revised or updated annually or as necessary in provision of care that meet current standards of practice. c. Develop and implement a policies and procedures addressing the way the Interdisciplinary Team ([group of different disciplines working together towards a common goal for a resident) authorized medical interventions for residents who were unable to provide informed consent and without a healthcare decision maker. These deficient practices placed the resident population at risk to not receive required care or necessary services needed.

Inspectors wroteBased on interview and record review, the facility failed to ensure: a. Advance directives (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) was offered, discussed, and written information was provided to the residents and/or responsible party for one of 20 sampled residents (Resident 11). b. Medical records included a copy of the advance directives for one of 20 sampled residents (Resident 71). These deficient practices violated the residents' and/or the representatives' right to be fully informed of the option to formulate their advance directives and had the potential to cause conflict with the residents' wishes regarding alternatives in the provision of health care.

Inspectors wroteBased on interview and record review, the facility failed to ensure any allegations of abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish), neglect and injuries of unknown source were reported to the state licensing agency, long term care ombudsman (agency to work with residents in long term care facilities with issues), and law enforcement agency within the time frame required for three of three sampled residents. The following incidents were not reported: a. Resident 21's allegations of abuse on 3/9/2022. b. Resident 90's fall incident on 2/25/2022 that resulted in a fracture (broken bone) of the Lumbar 1 (L1) to L3 (lower back) causing significant decline in activities of daily living ([ADLs] self-care activities performed daily such as dressing, personal hygiene, and grooming). c. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide documented evidence that all alleged violations were thoroughly investigated, within five working days of the incident, for three of three sampled residents and results were reported to the state survey agency and other officials in accordance with California state law for the following incidents: a. Resident 21's allegations of abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) on 3/9/2022. b. Resident 90's fall incident on 2/25/2022, that resulted in a fracture (broken bone) of the L1-L3 (injury that affect the lower back) causing significant decline in activities of daily living ([ADLs] skills required to independently care for oneself). c. Resident 93's unusual death on 3/11/2022. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and/or implement an individualized resident centered plan of care with measurable objectives, timeframes, and interventions for residents at risk for pressure sore (injury to skin and underlying tissue caused by prolonged pressure to the area) development and for the use of physical restraints for eight of 20 sampled residents (Residents 8, 21, 69, 80, 93, 6, 90, and 84). This deficient practice had the potential to negatively affect the delivery of necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify and provide needed care and services that were resident-centered with professional standards of practice for four of four sampled residents (Residents 36, 90, 93, and 345) This deficient practice had potential to cause a negative outcome for Resident 36, 90, 93 and 345.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of eight sampled residents (Residents 8 and 84) received care consistent with professional standards of practice, to prevent pressure ulcer development (are localized areas of injury that occur when skin and underlying tissue are compressed between a bony prominence and an external surface such as a mattress) and received necessary treatment and services to promote healing and prevent new pressure ulcers from developing. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure three of three sampled residents received adequate supervision to prevent accidents when: a. Resident 36 was physically restrained after multiple falls due to poor safety awareness related to dementia (progressive memory loss). b. Resident 90 had a fall incident on 2/25/2022 resulting in a L2-L3 fracture (broken bone of the second and third vertebrae of the lower spine). c. Resident 93 experience a choking incident resulting in left chest discoloration, the resident expired on 3/11/2022 These deficient practices placed all 93 residents currently residing in the facility at risk for any future accidents and/or death from inadequate staff supervision.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the following: a. All staff had an annual skills competency evaluation and annual performance evaluation. b. Staff was competent when administering single dose Ativan (medication used to treat anxiety [feelings of excessive worry, unease]) injections. c. Licensed Vocational Nurse 4 (LVN 4) maintained infection control (measures to prevent or control the spread of germs) when administering medications to three of three sampled residents (Resident 35, 55, and 4). These failures had the potential to negatively affect the quality of care received by the residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to: a. Accurately account for the administration of two controlled medications (medications with a high potential for abuse on the Narcotic Record (a log signed by the nurse with the date and time a controlled medication is given to a resident) for Residents 76 and 90. b. Accurately account the date for the use of one controlled substance on the Narcotic Drug Record for Resident 78. These deficient practices increased the facility's risk for the potential loss, diversion (transfer of a medication from a legal to an illegal use) or accidental exposure to controlled medications, and potential for harm to resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure three of three sampled residents (Resident 69, 21, 84) were free from unnecessary psychotropic medications (medication which affects the brain activities associated with mental process and behavior) when the facility failed to ensure: a. Resident 69 had an informed consent, a comprehensive care plan, a stop date limited to fourteen days, a gradual dose reduction, and documented physician rationale for the use of Zolpidem (medication to induce sleep). b. Resident 21's Depakote (used to treat seizures and bipolar disorder), Haldol (used to treat certain mental/mood conditions) and Zyprexa (treat certain mental/mood conditions) had a legal informed consent from a responsible party. c. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Label opened date for one multiple-dose influenza vaccine (medication to protect against a viral infection that attacks the respiratory system) vial (a small glass container). 2. Label opened date for one multiple-dose tuberculin (medication used to diagnose tuberculosis [TB], a potentially serious infectious bacterial disease that mainly affects the lungs) vial. 3. Label with a complete opened date for one multiple-dose tuberculin vial. 4. Discard one multiple-dose tuberculin vial that had expired. 5. Reseal one emergency kit ([E-kit] box containing a small quantity of medications that can be dispensed when pharmacy services are not available) containing controlled substances (medications with a high potential for abuse) after opening. 6. Re-order and replace one E-kit after opening. 7. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an updated policy and procedure was developed and implemented to determine underlying causes of problems in the facility. This deficient practice put the facility at risk for not maintaining an effective system to identify, collect and use data to improve services that could affect resident care during their stay in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: a. Licensed Vocational Nurse (LVN) 4 performed hand hygiene prior to administering medications to three of three residents (Residents 35, 55, and 4) observed during medication administration. b. Single-dose Ativan (medication used to treat anxiety [feelings of worry, unease]) vials were not used more than once for Resident 30. c. Resident 69's bed was not placed directly on the floor. These deficient practices had the potential to place the residents, staff, and the community at risk for the spread of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that maintained residents dignity and respect for one of 44 sampled residents (Resident 69) by placing the resident's mattress directly on the floor without a bed frame. This deficient practice had the potential to affect Resident 69's sense of self-worth and self-esteem.

Inspectors wroteBased on observation, interview, and record review the facility failed to protect one of three sampled residents (Resident 21) from abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) by: a. Failing to ensure Licensed Vocational Nurse 8 (LVN 8) reported abuse allegations (staff to Resident 21) to the Director of Nursing (DON) or Administrator (ADM). b. Failing to comprehensively assess, monitor, and notify Resident 21's physician and responsible party after the the resident's abuse allegations was reported by Certified Nurse Assistant 16 (CNA 16). These deficient practices placed Resident 21 at further risk for abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure self-reporting involving abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish), neglect, including injuries of unknown source to the state licensing agency, long term care ombudsman (agency to work with residents in long term care facilities with issues), and law enforcement agency within the time frame required was completed for three of three sampled residents by not reporting: a. Resident 21's allegations of abuse on 3/9/2022. b. Resident 90's fall incident on 2/25/2022 that resulted in a fracture (broken bone) of the Lumbar 1 (L1) to L3 (lower back) causing significant decline in activities of daily living ([ADLs] self-care activities performed daily such as dressing, personal hygiene, and grooming). c. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that pain management was provided for one of one sample resident (Resident 90). This deficient practice had the potential to result in lack of detection of unrelieved pain for Resident 90.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that resident bedrooms accommodated no more than four residents in four of 32 bedrooms (Rooms A, B, C, D). This deficient practice could adversely affect the adequacy of space, nursing care, comfort, and privacy to the residents and their visitors residing in Rooms A, B, C, and D.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staffing information was updated and posted in a visible and prominent place daily. This deficient practice resulted in inaccessibility to staff, residents, and visitors for accurate daily number of clinical staff required to care for residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet the required room size measurement of 80 square feet per resident in rooms with multiple residents. This deficient practice had the potential for inadequate space for each resident's privacy and safe nursing care.