Community Care and Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement fall interventions for one of four residents reviewed (Resident 4), when the toileting plan schedule for Resident 4 was not followed. Resident 4 experienced a repeated fall trying to use the bathroom and required transfer to acute hospital for further evaluation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the care plan indicating the resident was not to be assigned male Certified Nursing Assistants (CNAs) was implemented and communicated to staff members, for one of two residents, Resident 1. This failure resulted in Resident 1 being assigned to male CNAs and had the potential to result in Resident 1 to feel afraid and uncomfortable.

Inspectors wroteBased on interview and record review, the facility failed to ensure documentation was completed according to professional standards of practice for two of six residents (Residents 1 and 2) reviewed when:1. For Resident 1, Hydralazine Hydrochloride oral tablet (a medication used to treat high blood pressure) was not administered on April 18 and 19, 2026; and2. For Resident 2, Metoprolol Succinate Extended-Release (ER) oral tablet (a medication used to treat high blood pressure) was not administered on May 2 and 3, 2026. There were no documented blood pressure (B/P) parameters indicating the need to hold Resident 1 and 2's blood pressure medication resulting in incomplete medical records.

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility's policy and procedure was followed for one of three residents (Resident 1) when Resident 1's request to be discharged , and the facility's referral and coordination with a placement agency were not documented in the medical records. This failure had the potential to result in an inappropriate discharge.

Inspectors wroteBased on interview and record review, the facility failed to ensure, for one of three residents, Resident 2, clinical findings demonstrating the necessity of inserting an indwelling Foley catheter (IFC- a thin, hollow tube inserted through the urethra into the urinary bladder to collect and drain urine) were documented in the medical record. In addition, the facility failed to initiate a care plan addressing Resident 2's use of IFC.This failure had the potential for unnecessary use of an IFC and resulted in Resident 2 having a urinary tract infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four residents reviewed (Resident 1) was monitored and supervised to prevent a fall. This failure had the potential to cause injury and harm to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure five of 28 sampled residents (Residents 7, 10, 47, 182, and 187) received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, when: 1. For Residents 7, 10, 47, and 182, the nursing staff did not rotate subcutaneous (under the skin) insulin injection sites in accordance with the facility policy and procedures (P&P). Additionally, for Residents 7 and 47, the nursing staff did not notify the doctor when blood sugar (BS) results were below 70 in accordance with the doctor's insulin (medication to treat diabetes) sliding scale (a chart with insulin doses to maintain blood sugar levels) order; and 2. For Resident 187, the nursing staff did not monitor and document the respiratory rate as indicated in the resident's care plan on March 23, 24, and 25, 2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure provision of pharmacy services met the needs of the residents when three (3) of five (5) residents reviewed (Residents 94, 97, and 110) were missing documentation for the administration of controlled substance (CS, those with high potential for abuse and addiction) medications. The CS medication was signed out of the Controlled Drug Record (an inventory sheet that keeps record of the usage of controlled medications) but not documented on the Medication Administration Records (MAR) to indicate it was administered to the residents. These failures resulted in inaccurate accountability of CS medications, which had the potential for misuse or diversion.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Food and Nutrition Services staff were trained and competent to carry out the functions of the department safely and effectively when: 1. Multiple Food and Nutrition Services staff, including the Registered Dietitian, did not follow professional standards of practice using three separate steps (wash, rinse and sanitize) to clean and sanitize food contact surface. Failure to properly clean and sanitize food contact surface results in growth of microorganisms on food contact surface and could cross-contaminate food; 2. Two staff members (Cook 1 and [NAME] 2) did not know the correct concentration of the sanitizer (sanitizing solution used for sanitizing food contact surfaces); 3. [...]

Inspectors wroteBased on dietary observations, dietary staff interviews and record reviews, the facility failed to ensure: 1. [NAME] 2 followed the recipe when preparing an alternative meal during lunch on 5/5/25; 2. [NAME] 4 followed the recipe when preparing pureed bread during lunch on 5/6/25; and 3. [NAME] 4 folowed the recipe when preparing Buttered Carrots during lunch on 5/6/25. Failure to follow standardize recipes may result in the preparation of a meal that did not meet the physician ordered diet. Failure to follow recipes may also result in a product that is not palatable which may result in decreased meal intake in a medically vulnerable residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the appropriate food textures was provided when two residents (Resident 15 and 81) out of two sampled residents who receives Soft and Bite-Sized diet (a diet with food texture need to chop up or pureed into small piece for residents who have limited swallowing ability) received a regular texture bread stuffing without gravy for lunch on 5/5/2025. This failure had the potential to place the residents at risk of choking.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the physician's prescribed diet order when: 1. Heart Healthy diet was given the food item that was not consistent with the [NAME] Spreadsheet; and 2. Renal and Liberal House Renal diets were given the food item that was not consistent with the [NAME] Spreadsheet on 5/525 and 5/6/25. These failures had the potential to negatively impact the residents' nutritional status and further compromising resident's medical status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a sanitary environment, prepare, and served food in accordance with professional standards for food service safety when: 1. Raw meats were holding for extended periods of time for thawing; 2. Multiple pieces of equipment that were not clean to sight and/or touch found in kitchen; 3. Multiple areas and pieces of equipment covered with dust were found in kitchen; 4. Storage shelves at dry storage did not have smooth surface; 5. Screened door at dry storage had gap; 6. Two non-dietary staff entered the kitchen without hairnets; 7. Personnel belongings found at dry storage; 8. Dry storage shared with dietary staff break room; and 9. Expired foods found at resident's refrigerator. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to dispose of garbage and refuse properly when trash were found outside on the floor surrounding the dumpsters. In addition, the lids of the dumpsters did not close properly. This failure had the potential to attract pests.

Inspectors wrote2. On May 5, 2025, at 1:57 p.m., an observation and concurrent interview was conducted with Resident 183. Resident 183 was lying in bed, awake, alert, and able to verbalize his needs. An oxygen concentrator (a device that extracts oxygen from the air and delivers a concentrated oxygen to the patient) was observed at the bedside, with oxygen nasal cannula tubing (a thin flexible tube with two prongs that delivers oxygen through the nose) connected to the concentrator. The nasal cannula tubing was observed inside the upper drawer of the resident's nightstand. Resident 183 stated he had not used his oxygen for two weeks. He stated he felt fine without the oxygen. On May 6, 2025, at 2:03 p.m., an interview was conducted with Certified Nursing Assistant (CNA) 4. CNA 4 stated Resident 183 only used his oxygen as needed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light system (a communication system that allow the resident to call for staff assistance) located in Station 2 had an adequate audible sound. This failure had the potential for the residents located in Station 2 not to receive assistance from the staff in a timely manner.

Inspectors wroteBased on interview and record review, the facility failed to ensure three (3) of five (5) residents reviewed (Residents 4, 10, 182) were free from unnecessary psychotropic (drugs that affects brain activities associated with mental processes and behavior) medications including venlafaxine (an antidepressant medication used for depression [mental health condition characterized by persistent feelings of sadness] , anxiety [human emotion charaterized by feelings of unease, worry, or fear], and panic disorder [brief episode of intense anxiety, which causes the physical sensation of fear]) and Seroquel (an antipsychotic medication for bipolar disorder [disorder associated with episodes of mood swings ranging for depressive lows to manic highs], depression, and schizophrenia [chronic brain disorderthat affects thinking, feeling, and behavior]) when: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse involving one of three residents reviewed (Resident 55) to California Department of Public Health (CDPH) immediately, but not later than 2 hours after the allegation was made. The facility staff was made aware on April 13, 2025. This failure resulted in the delay of abuse investigation, that placed Resident 55 and other residents at risk when the Certified Occupational Therapy Assistant (COTA) was not suspended immediately in accordance with the facility's policy and procedure.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the comprehensive care plans were developed and implemented when: 1. For Resident 10, the care plan for the use of Effexor (brand name for venlafaxine, an antidepressant medication used for depression, anxiety, and panic disorder) XR (extended release, designed to release medicine slowly into the body over a prolonged period) was not initiated and developed. This failure had the potential to increase Resident 10's risk of not being provided appropriate, consistent, and individualized care. 2. For Resident 11, the care plan for the right leg edema was not initiated and developed. This failure had the potential not to be able to meet the person-centered goals and objectives for Resident 11's right leg edema and delay the necessary care and services for her recovery and discharge.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe smoking practices were observed and implemented for two of 12 residents reviewed for smoking, when: 1. Resident 29's cigarettes were not stored in the lock box provided by the facility; and 2. Resident 84's smoking materials (cigarettes and lighter) were not stored in the lock box provided by the facility. These failures had the potential to result in accidents or injuries to the facility residents.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities during the monthly medication regimen review (MRR) when Resident 4 received Seroquel (an antipsychotic medication for bipolar disorder, depression, and schizophrenia) without manufacturer specified monitoring. This failure had the potential for medications not being optimized for best possible health outcome, and increased risk for adverse effects for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the lubricant eye drops solution was safely stored for one of 28 residents reviewed (Resident 186). This failure resulted in Resident 186 administering the eye drops solution without physician's order, self-administration assessement, and supervision. In addition, this placed Resident 186 at risk for unsafe medication administration and has the potential to alter the efficacy of the eye drops solution being stored at resident's bedside.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Dietary Supervisor (DSS - the position responsible for the day-to-day operation of the dietary department), met the educational requirements as outlined in the Federal Regulation, and California Health and Safety Code.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that bedrooms measured at least 80 square (sq) feet (ft) per resident, in bedrooms occupied by multiple residents (Rooms 101, 106, 107, 112, 119, 121, 123, and 125).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure for one of three residents (Resident 1), their family member was notified of Resident 1 's room change. This failure resulted in Resident 1 's Family Member, to be unaware of Resident 1's location within the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure for one of three residents, Resident 1, that her open wound was assessed and treated after she informed a staff member about it. This failure resulted in the delay of assessment and treatment of Resident 1 's open wound and had the potential for the wound to become infected.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when Certified Nurse Assistant (CNA) 2 did not wear the appropriate personal protective equipment (PPE - specialized clothing or equipment worn to create a barrier between healthcare workers and potential sources of infection, like blood, body fluids, or other potentially infectious materials) when she entered the room of a COVID-19 (a highly contagious respiratory disease) positive resident. This failure had the potential to spread COVID-19 to other residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light was functioning for one of three residents, Resident 3. This failure resulted in Resident 3 waiting for a long time to be assisted with toileting hygiene.

Inspectors wroteBased on interview and record review, the facility failed to ensure facility policy and procedures were implemented to prevent and identify the development of a pressure injury (PI- bed sore) for one of two sampled residents (Resident 1), when an open area of the skin identified on Resident 1 ' s sacrum (a large, triangular bone at the base of the spine) on August 30, 2024, was not assessed and was not provided treatment. These failures resulted in Resident 1 developing a stage 3 PI (full -thickness tissue loss, exposing fat tissue) which was identified on September 13, 2024.

Inspectors wroteBased on interview and record review, the facility failed to provide a notice of proposed discharge to one of three residents, Resident 2, when Resident 2 was discharged from the facility after being transferred to the general acute care hospital (GACH). In addition, the facility failed to notify the Long-Term Care (LTC) Ombudsman (an advocate for residents and families in long-term care facilities) and Resident 2's family member (FM) of Resident 2 ' s discharge from the facility. This failure placed Resident 2 at an increased risk of being discharged without having an advocate to ensure a safe and effective transition of care, or without having a clear understanding of his appeal and discharge rights.

Inspectors wroteBased on interview and record review, the facility failed to ensure, for one of three residents reviewed, Resident 2, who was transferred to General Acute Care Hospital (GACH) on March 27, 2024, was re-admitted back to the facility on the first available bed. This failure resulted to a violation of Resident 2's right to be re-admitted back to the facility to the first available bed and had the potential to cause emotional distress.

Inspectors wroteBased on record reviews, interviews, and facility policy review, the facility failed to ensure the Minimum Data Set assessments were accurate for 2 (Resident #9 and Resident #147) of 29 sampled residents. Specifically, the facility incorrectly coded Resident #147 being discharged to the hospital instead of home and did not accurately code Resident #9's level II preadmission screening and resident review (PASARR) status.

Inspectors wroteBased on observation, interviews, and facility policy review, the facility failed to ensure residents' rooms measured at least 80 square (sq) feet (ft) per resident in 8 (Rooms 101, 106, 107, 112, 119, 121, 123, and 125) of 71 resident rooms in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's water temperatures were maintained at a comfortable level for two of five residents reviewed (Resident 2 and 5) when the resident's and/or resident ' s representatives (RR) complained the hot water took too long to heat in their bathrooms. This failure had the potential for the residents to feel uncomfortable and affect their quality of life.

Inspectors wroteBased on interview, and record review the facility failed to ensure, for one of five residents reviewed (Resident 1), professional standards of practice were followed when the physician ' s order for follow up appointment was not carried out on January 26, 2024. This failure had the potential for care and services for Resident 1 to be delayed.

Inspectors wroteBased on interview and record review, the facility failed to implement interventions which had the potential to result in, and/or contribute to, the worsening of a pressure injury/ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) for one of five residents (Resident 1), when Resident 1 was admitted to the facility with a pressure ulcer/injury on the coccyx (base of the spine) and there were no documented skin assessments after admission. This failure had the potential to place the resident at an increased risk for pain and infection.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of verbal abuse involving a resident (Resident 1) and a Licensed Vocational Nurse (LVN 1) to the State Survey Agency immediately, but not later than two hours after the allegation was made. This failure had the potential to result in further abuse and harm for the resident involved.

Inspectors wroteBased on interview, and record review, the facility failed to notify one (Resident 1) of three sampled residents Responsible Person (RP; person designated as being responsible for another person's medical and financial decisions) of a change in condition and had to be admitted to the acute care hospital setting. This failure resulted in violation of Resident 1's rights.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain resident's safety and provide adequate supervision specific to residents with cognitive impairment, wandering behavior, and risk for elopement (leaving a facility without notice) for one of three residents reviewed (Resident 1). In addition, the facility failed to implement safety measures to secure the main entrance door where Resident 1 exited the facility. This failure resulted in Resident 1's elopement and increased the potential to expose Resident 1 to harm, accidents, injury and illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food safety requirements for food storage and preparation were followed when: 1(a) Multiple food items stored in the dry storage area were not labeled with the name of the food item, the opened date, or use-by date; 1(b) Multiple food items stored in the refrigerator were not labeled with opened dates or use-by dates; 2. The kitchen ice machine had a yellowish-brown slimy substance located on the inside cover; and 3. The kitchen manual can opener had an accumulation of a dry reddish brown stain on and around the blade and on the base of the can opener. These failures had the potential to place the residents of the facility at risk for food-borne illness in a medically vulnerable resident population who consumed food in the facility. The facility census was 125.

Inspectors wroteBased on interview and record review, the facility failed to ensure there was documented evidence Advance Directive (written instruction related to the provision of health care when the resident is no longer able to make decisions) information was provided to the resident and/or responsible party (RP), for four of 22 residents reviewed (Resident 32, 75, 80, and 114). This failure had the potential for Residents 32, 75, 80, and 114, not to be able to exercise their rights to formulate an Advance Directive.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure four of 32 residents reviewed for care and treatment (Residents 63, 75, 100, and 379) maintained their highest practicable physical well-being when the facility did not identify and assess a dark bluish skin discoloration (bruises) for Residents 63, 75, 100, and 379 in a timely manner. This failure had the potential for Residents 63, 75, 100, and 379, to not receive care and treatment for the skin discolorations and may result in a delay in the investigation to determine the cause of the skin discolorations.

Inspectors wroteBased on interview and record review, the facility failed for three sampled residents (Resident 42, 24, and 115) to ensure: 1. For Resident 42, a pain assessment was conducted and non-pharmacological interventions were provided by the licensed nurse prior to administering the PRN (medication taken only as needed) Percocet (a narcotic pain medication) on June 5, 6, 7, and 8, 2021; 2. For Resident 24, a pain assessment was conducted and non-pharmacological interventions were provided by the licensed nurse prior to administering the PRN Norco (a narcotic pain medication) on June 9, 2021; and 3. For Resident 117, a pain assessment was conducted and non-pharmacological interventions were provided by the licensed nurse prior to administering the PRN Norco on May 17, 18, and 30, 2021. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control precautions to prevent cross contamination and maintain a sanitary environment when: 1. Two Treatment Nurses were observed providing wound care to Resident 7 after the lunch meal tray was served; 2. Two staff were observed to have artificial fingernails when assisting a resident while eating and when checking the resident's meal tray; and 3. One Licensed Nurse was observed wearing gel nail polish and nail enhancements during a medication administration observation. These failures increased the risk of cross-contamination which could result in the development and transmission of infections to a vulnerable population of 125 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide meal service in a dignified manner for one of 10 residents (Resident 66) observed during lunch when the facility did not serve the resident's lunch at the same time as her roommate (Resident 36) while both residents were inside the room. This failure resulted in Resident 66 watching her roommate eat before she was served, which had the potential to cause feelings of decreased self worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident was safe to self-administer medications, for one resident (Resident 60) reviewed for self-administration of medications. This failure had the potential for Resident 60 to self-administer medications unsafely.

Inspectors wroteBased on interview and record review, the facility failed to ensure, for one of eight sampled residents (Resident 8), the professional standard of practice was followed when there was missing documentation to indicate nasal iodophor 10% antiseptic (a substance that stops or slows down the growth of microorganisms) was administered as ordered. This failure resulted in inaccurate documentation of Resident 8's care potentially resulting in unnecessary changes to Resident 8's plan of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three residents (Resident 328) reviewed for ADL (Activities of Daily Living) was provided with nail care. This failure resulted in Resident 328 to not receive services for proper grooming and personal hygiene.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their policy and procedure on safe smoking practices for three of 19 residents (Residents 1, 51 and 115) reviewed for smoking when: 1. Resident 1's smoking materials were not kept in a locked box. 2. Resident 51 smoked in his own patio and not in the designated smoking area; Further, he used oxygen at night and as needed during the day; and 3. Resident 151 did not have a smoking apron on while smoking, and was unsupervised by facility staff while smoking. These failures had the potential to increase the residents' risks for smoking related injuries and accidental fires.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the menu was being followed for the therapeutic diet on June 7, 2021, during lunch meal observation when: 1. Resident 16, who was on a double portion regular texture NAS (no added salt) diet did not receive an orange or melon slice as indicated on the menu; and 2. Resident 36 who was on a regular puree (regular diet modifies in texture of a smooth and moist consistency and able to hold its shape. Foods usually in soft and smooth state such as pudding or mashed potatoes) diet did not receive egg noodles and parsley flakes as indicated on the menu. These failures had the potential to result in compromising the medical and nutritional status of Residents 16 and 36.

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve food to meet the individual needs for one of three sampled residents (Resident 380) reviewed for nutrition, when Resident 380 was served a puree (regular diet modified in texture to a smooth and moist consistency and able to hold its shape. Foods usually in a soft and smooth state such a spudding or mashed potato) diet for breakfast, lunch and dinner on June 9, 2021, inconsistent with the physician's diet order. The facility failure had the potential to negatively affect Resident 380's intake which could result in compromised nutritional status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, ten residents' bedrooms measured at least 80 square feet (sq. ft.- a unit of measurement)) per resident, in bedrooms occupied by multiple residents (Rooms 101, 106, 107, 108, 112, 117, 119, 123, 125, and 217). These failures have the potential to have an adverse effect on the residents' health and safety, and may impede the ability of the residents in these rooms, to attain their highest practicable level of mental, physical, and psycho-social well-being.