Covina Rehabilitation Center

Inspectors wroteBased on interview and record review, the facility failed to ensure the accuracy and completeness of an informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for the use of psychotropic medications (any drug that affects brain activities associated with mental processes and behavior) for two of two sampled residents (Residents 8 and 74) by failing to:a. Ensure Resident 8's informed consent for the use of Ativan (medication to treat anxiety [feeling of worry, fear or nervousness]) was dated when the informed consent was obtained.b. Ensure Resident 74's informed consent for the use of Seroquel (medication to treat mental health condition) indicated the name of the person giving the consent. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services to prevent skin breakdown, promote wound healing and skin maintenance for two of four sampled residents (Residents 7 and 45) by failing to:a. Ensure staff trimmed the fingernails and provided a pressure-relieving barrier between the fingers, contracted thumb, and palm of the right hand for Resident 7 who was assessed as high risk for pressure ulcer (a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear) development. This deficient practice resulted in Resident 7 developing skin indentations (depression or dent on the skins surface) and discoloration in the palm of Resident 7's hand and placed Resident 7 at risk for development of right-hand pressure ulcers. b. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three of seven sampled residents (Residents 7, 9, and 12) received appropriate services to prevent a decline or maintain joint (where two bones meet) range of motion (ROM, full movement potential in a joint) and mobility (ability to move) by failing to: 1. For Resident 7, provide Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) evaluation and treatment to assess proper fit and wear time for Resident 7's right-hand splint (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) after Resident 7's custom right hand splint was lost. 2a. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe food storage practices in one of two residents' refrigerators (Refrigerator 1), by failing to:a. Discard a plate containing three (3) meat tacos with no expiration date.b. Discard a container with pizza that had no expiration date.c. Discard a container of watermelon dated 6/11/26.d. Discard a cup containing mango slices with no expiration date. These deficient practices had the potential to result in food-borne illnesses (illness caused by ingesting contaminated food or beverages) for the residents. During an observation and interview with the Dietary Supervisor (DS) on 6/16/26 at 8:44 AM, the DS stated the residents' refrigerator was located inside the activity room on the 2nd floor. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and follow infection prevention procedures to prevent the transmission of infectious organisms for two of five sampled residents (Residents 76 and 82) by failing to: a. Ensure Registered Nurse 1 (RN 1) wore required personal protective equipment (PPE, equipment that protects people from injury or illness) while providing care to Resident 76 who was placed on Enhanced Barrier Precaution (EBP, precautions that involve using a glove and gown during high-contact resident care activity for residents colonized or infected with multidrug-resistant organisms [MDRO, bacteria that is resistant to many types of antibiotics] and those at a higher risk of developing MDRO, such as residents with wounds or indwelling medical devices). b. Ensure Resident 82 had a urinal holder to hang the used urinal. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow its Antibiotic stewardship program (a coordinated healthcare initiative designed to promote the most appropriate, safe, and effective use of antibiotics [medication that kills or stops bacteria [microscopic single-celled organisms, some can cause illness] from reproducing]) by failing to prescribe antibiotics appropriately for three (3) of five (5) sampled residents (Residents 2, 15, and 77). These deficient practices had the potential to result in unresolved infections (the invasion and growth of germs in the body) and physical declines due to the inappropriate use of antibiotics for Residents 2, 15, and 77.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call light was within reach and appropriate to the resident's physical ability for one of three sampled residents (Resident 7). This failure had the potential for Resident 7 not to receive necessary care or receive delayed services to meet Resident 7's needs. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of one sampled resident's (Resident 3) fluid intake was monitored as ordered and in accordance with facility's policy and procedure (P&P) titled Care of Resident Receiving Renal Dialysis. This failure had the potential for complications related to electrolyte (minerals in the body) imbalance for Resident 3.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to elevate the resident's head of the bed (HOB) while receiving feeding (formula) through the gastrostomy tube (GT - a tube inserted through the abdomen that delivers nutrition directly to the stomach) in accordance with the resident's care plan and physician's order for one of five sampled residents (Resident 76). This deficient practice had the potential to result in aspiration (inhalation of foreign materials) and pneumonia (a lung infection) for Resident 76.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to ensure one of three sampled residents (Resident 47) received two liters of oxygen per minute continuously through nasal cannula according to the physician's order. This deficient practice had the potential to result in respiratory complications for Resident 47 associated with oxygen therapy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Restorative Nursing Assistant 1 (RNA 1) (RNA, a Certified Nursing Assistant who is trained to assist residents with restorative care such as exercises, walking, and restorative equipment) was competent in providing RNA services to one of seven sampled residents (Resident 7) for splinting (applying and/or removing splint(s) [device used to immobilize a body part]) when RNA 1 did not apply Resident 7's custom right-hand splint as ordered by the physician. This deficient practice had the potential to cause Resident 7 and other residents receiving RNA services in the facility to experience pain, injury, and skin breakdown (tissue damage caused by friction, shear, moisture, or pressure). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Certified Nursing Assistant (CNA) 4 provided care and services to prevent a fall (move downward, typically rapidly and freely without control, from a higher to a lower level) for one of four sampled residents (Resident 1), according to the facility's policy and procedure (P&P) titled, Safe Lifting and Movement of Residents, and the Inservice on the use of Hoyer lift (mechanical [made or operated by a machine] lift - a device used by staff to lift and transfer residents from bed to a chair or one location to another), dated 2/19/2025 by failing to: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient number of nursing staff according to the facility's policy and procedure (P&P) titled, Staffing, Sufficient and Competent, and Facility Assessment Tool (FA Tool), by failing to: 1. Ensure certified nursing assistants (CNA) were not assigned more than 12 residents on 5/6/2025, 5/7/2025, 5/14/2025, 5/15/2025, and 5/18/2025 on the 11 pm to 7 am (noc) shift on Station 3. 2. Ensure there were seven assigned CNAs on the 7 am to 3 pm (morning) shift in Station 3 on 5/26/2025. As a result of these failures, on 5/6/2025, 5/7/2025, 5/14/2025, 5/15/2025, and 5/18/2025 CNAs working in Station 3 were assigned between 24 and 25 residents during the noc shift. On 5/26/2025, there were five CNAs working in Station 3 during the AM shift. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure nursing staff had the appropriate skills and competency necessary to provide nursing care and services to one of four sampled residents (Resident 1), according to the facility's policy and procedure (P&P) titled, Staffing, Sufficient and Competent Staffing, and the Inservice on the use of Hoyer lift (mechanical [made or operated by a machine] lift - a device used by staff to lift and transfer residents from bed to a chair or one location to another), dated 2/19/2025 by failing to: Ensure Certified Nursing Assistant (CNA) 4 provided two-person physical assistance (help from two persons) to transfer (moving a resident from one place to another) Resident 1 from Resident 1's bed to the shower gurney (mobile bed used to assist in bathing residents) when CNA 4 used the Hoyer lift. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the pad sensor/call lights were within reach for three of three sampled residents (Residents 9, 14, and 34). These failures had the potential for the residents not to receive or receive delayed care that could result in a fall or accident.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of three sampled residents' (Resident 16 and 23's) swallowing/nutritional status was accurately assessed and coded in Resident 16 and 23's Minimum Data Set (MDS- a resident assessment tool). This deficient practice resulted in inaccurate reporting to the Centers for Medicare and Medicaid Services (CMS, a federal agency that administers major healthcare programs in the United States) and had the potential for Residents 16 and 23 to not receive interventions to address specific care concerns.

Inspectors wroteBased on observation, interview, and record review, the facility failed to change the dressing (a clean or sterile covering) every seven (7) days for two of two sampled residents' (Resident 63's and 294's) central line (a flexible tube inserted into a vein in the neck, chest, arm or groin) and midline intravenous (IV- existing or taking place within a vein/s) catheter (a long, thin, flexible tube that is inserted in the upper arm with the tip located just below the axilla [armpit]) in accordance with Resident 63's and Resident 294's care plan and the facility's policies and procedures (P&P) titled, Midline Catheter Dressing Change, and Peripheral and Midline IV Dressing Changes. This failure had the potential to result in an infection for Resident 63 and 294 and worsen Resident 63's and 294's health condition.

Inspectors wroteThe facility failed to provide a 24-hour sufficient nursing staffing on one of fourteen Saturdays and one of fourteen Sundays for Quarter 1 of 2024 (10/1/2024 to 12/31/2024) consistent with Payroll Based Journal (PBJ, a system for collecting and reporting staffing information from nursing homes and other long-term care facilities) Staffing Data Report. The facility did not meet the required 2.4 Certified Nursing Assistant (CNA) direct care hours per patient day on 12/1/2024 and 12/14/2024. These failures had the potential to affect the quality of care and negatively affect the resident's quality of life in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of three sampled residents (Residents 35 and 89) were not administered Epoetin Alfa-epbx (Epogen, a medication to treat anemia [a condition when the blood does not have enough red blood cells or reduced amount of hemoglobin [Hgb, a protein in red blood cells that carries oxygen throughout the body]) injections as indicated in Residents 35 and 89's physicians orders (PO) to hold Epogen injections when Residents 35 and 89's Hgb level was > (more than) 10 grams per deciliter (g/dl, unit of measurement for Hgb). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide safe and sanitary environment to help prevent the development and transmission of communicable diseases for three of five sampled residents (Residents 5, 24, and 1) by failing to: a. Ensure staff implemented the facility's Policy and Procedure (P&P) titled, Enhanced Barrier Precaution (EBP, precautions that include the use of a gown and gloves during high contact resident care activities for residents), to prevent the spread of infections for Residents 5 and 24. b. Ensure Resident 1's oxygen tubing was not on the floor. These failures had the potential to result in transmission of multidrug-resistant organisms (MDRO, bacteria that is resistant to antibiotics (medicine used to stop or kill the growth of bacteria) to other residents in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide privacy for one of 22 sampled residents (Resident 69) when staff did not close the privacy curtain while checking Resident 69's Gastrostomy tube (G-tube, feeding tube that is surgically placed through an opening into the stomach from the abdominal wall) site. This deficient practice violated Resident 69's right to bodily privacy and resulted in unnecessary exposure of Resident 69's abdominal area and lower extremities. This deficient practice had the potential to affect Resident 69's psychosocial (mental and emotional) well-being, self-esteem, and self-worth.

Inspectors wroteBased on interview and record review, the facility failed to complete a discharge assessment Minimum Data Set (MDS, a standard resident assessment and care screening tool) per Center of Medicare & Medicaid Service (CMS- a federal agency that provides health coverage and focuses on improving the quality and outcome within the healthcare system) requirement for one of one sampled resident (Resident 82). This failure had the potential for inaccurate reporting to CMS and for Resident 82 not to receive necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop an individualized and comprehensive communication plan of care for one of one sampled resident (Resident 50) with language barrier. This failure resulted in Resident 50 not receiving individualized care and did not maintain the resident's highest physical and mental well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the bed alarm in proper working and functional condition for one of three sampled residents (Resident 34) reviewed for accidents and hazards. This failure placed Resident 34 at risk for a preventable fall/accident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) to change the face mask (an oxygen delivery device) for breathing treatment every seven days for one of three sampled residents (Resident 35). This failure had the potential to result in infection for Resident 35.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its policy and procedure (P&P) titled, Bed Safety and Bed Rails, for one of one sampled resident (Resident 5) when staff did not attempt alternative interventions prior to the use of bed rails and did not obtain informed consent for the use of bed rails for Resident 5. These failures placed Resident 5 at risk for entrapment (an event in which resident was caught, trapped, or entangled in a tight space around the bed) and injury from the use of side rails and to be uninformed about the risks and benefits of side rails.

Inspectors wroteBased on interview and record review, the facility failed to ensure complete and accurate documentation for one of one sampled resident (Resident 37) on a Low Air loss Mattress (LAL- a medical mattress designed to prevent and treat pressure wounds) when Resident 37's use and monitoring of LAL was not documented in Resident 37's Treatment Administration Record (TAR). This failure resulted in Resident 37's medical record to contain incomplete information and had the potential to affect Resident 37's care.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of eight sampled employees (Certified Nurse Assistant [CNA] 4) had performance evaluation completed annually. This failure had the potential for CNA 4 to not receive feedback on CNA 4's job performance and not be aware of areas that needed improvement in CNA 4's provision of patient care.

Inspectors wroteBased on observation, interview and record review, the facility failed to post the total number of licensed and unlicensed nursing staff directly responsible for resident care per shift daily in accordance with the facility's policy and procedure (P&P) titled, Posting Direct Care Daily Staffing Numbers. This deficient practice had the potential to result in residents and/or visitors not knowing the facility's nursing staffing information.

Inspectors wroteBased on interview and record review, the facility failed to revise a care plan (CP) for one of three sampled residents (Resident 1) when Licensed Vocation Nurse 1 (LVN 1) failed to provide safe seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) management for Resident 1 while Resident 1 experienced a seizure on 10/9/2024 as indicated in Resident 1's CP titled, Seizure Disorder and the facility's policies and procedures (P&P) titled, Emergency Procedure -Seizure Management and Care Plans, Comprehensive Person-Centered. This failure had the potential to result in inconsistent provision of treatments and services, unmet individualized needs for Resident 1, and the potential to affect Resident 1's physical and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to provide safe seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) management for one of three sampled residents (Resident 1) as indicated in the facility's policy and procedure (P&P) titled, Emergency Procedure -Seizure Management and Resident 1's CP titled, Seizure Disorder. On 10/9/2024 Resident 1 experienced a seizure and Licensed Vocation Nurse (LVN 1) wrapped a tongue depressor and inserted the tongue depressor in Resident 1's mouth. This failure had the potential to result in chocking to Resident 1 and the potential to result in a decline in Resident 1's physical well-being.

Inspectors wroteBased on interview and record review, the facility failed to readmit one of one sampled resident (Resident 1) from General Acute Care Hospital (GACH) 1 after Resident 1 was cleared by GACH 1 to return to the facility on [DATE]. This deficient practice had the potential to result in the denial of Resident 1's rights to return to the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received his pain medication as ordered by the physician. This failure resulted in Resident 1 to feel mad and had the potential for Resident 1 to experience unrelieved pain.

Inspectors wroteBased on interview and record review, the facility failed to ensure the supply of pain medication for one of three sampled residents (Resident 1) was refilled/restocked timely (promptly/without delay) and readily available when Resident 1 needed the medication. This failure resulted in Resident 1 to feel mad and had the potential for Resident 1 to experience unrelieved pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of five sampled residents (Residents 4, 5, and 6) had a comfortable and homelike environment for three days when the facility failed to ensure the air temperatures were safe and comfortable in nine of 20 resident rooms, according to the facility's policy and procedure (P&P) titled, Homelike Environment, revised February 2021. This failure resulted in Residents 4, 5, and 6 being uncomfortable and had the potential to negatively affect residents' (in general) health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to promptly (quickly/timely) notify the physician for two of six sampled residents (Resident 2 and Resident 3) who experienced a change of condition (COC- a sudden clinically important deviation from a resident/patient's baseline in physical, behavioral, or functional domains) as indicated in Resident 2's untitled care plan (CP) for fall risk, Resident 3's untitled CP for urinary catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag), and the facility's policies and procedures (P&P) titled, Change in a Resident's Condition or Status, by failing to: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement the care plans (CP) for one of six sampled residents (Resident 2), based on the facility ' s policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, by failing to: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two of six sampled residents (Resident 2 and Resident 3) electronic medical record (EHR) contained accurate and complete information by failing to: 1. Ensure staff completed and documented a Change of Condition (COC- a change in the resident's health or functioning that requires further assessment and intervention)/Interact Assessment Form (Situation-background-Assessment-Recommendation [SBAR- a written communication tool that helps provide essential, concise information, usually during crucial situations]) and a care plan (CP) after Resident 3 sustained a cut on the finger during trimming of fingernails. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the facility's policy and procedure titled, COVID-19 (highly contagious disease caused by the SARS-CoV-2 virus that is spread through inhalation or contact of droplet particles into eyes, nose, or mouth) Policy by failing to: 1. Ensure Maintenance Worker (MW) 1 donned on (put on) personal protective equipment (PPE, equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) prior to entering a COVID-19 positive room. 2. Ensure Family Member (FM) 1 donned on PPE prior to entering a COVID-19 positive room. These failures had the potential to result in the spread of COVID-19 virus to residents, staff, and visitors in the facility.

Inspectors wroteBased on interview and record review, the facility failed to screen and offer the Coronavirus (COVID-19, highly contagious disease caused by the SARS-CoV-2 virus that is spread through inhalation or contact of droplet particles into eyes, nose, or mouth) vaccine to four of six sampled residents (Residents 1, 2, 4, and 5) as indicated in the facility's policy and procedure (P&P) titled, COVID-19 Policy. This failure had the potential to result in Residents 1,2,4, and 5 to develop COVID-19 and serious respiratory complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a call light was within reach for one of six sampled residents (Resident 6). This deficient practice had the potential to result in the delay of care for Resident 6 when Resident 6 was unable to reach the call light to call staff for assistance.

Inspectors wroteBased on interview and record review, the facility failed to protect the personal property of one of six sampled residents (Resident 3) from theft and loss by failing to inventory (make a complete list of) Resident 3's personal belongings on admission as indicated in the facility's policy and procedure (P&P) titled, Personal Property. This deficient practice placed Resident 3's personal belongings at risk of theft and loss and could negatively affect Resident 3's psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 2) remained free from physical restraint (any manual method, physical or mechanical device, equipment, or material that is attached or adjacent to a resident's body, cannot be easily removed by a residents, and restricts the resident's freedom of movement or access to their body) for use of convenience (the result of any action that has the effect of alerting a resident's behavior and requires a lesser amount of care or effort, and is not in a resident's best interest) as indicated in the facility's policy and procedure (P&P) titled, Physical Restraint, by failing to: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services to prevent a fall (move downward, typically rapidly and freely without control, from a higher to a lower level) for one of six sampled residents (Resident 2), who was at high risk for falls, and as indicated in the facility's policies and procedures (P&P) titled, Safety and Supervision of Residents, and Falls and Fall Risk, Managing, by failing to: Ensure Resident 2's bed alarm/pad alarm (sensor pad device placed under a resident's bottom containing sensors that triggers an alarm when it detects a change in pressure, used as an early alert when a resident is trying to get out of bed) was working/functioning on the morning of 8/28/2024 prior to Resident 2 sustaining a fall. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide education for the Influenza (the Flu, contagious respiratory illness that affects the nose, throat, and lungs which can be prevented by getting the Flu vaccine) vaccine for one of six sampled residents (Resident 5). This failure had the potential to result in Resident 5 and/or Resident 5's responsible party being unaware of the benefits and potential side effects of the Flu vaccine.

Inspectors wroteBased observation, interview, and record review, the facility failed to ensure standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) were followed in accordance with the facility's policy and procedure and the Centers for Disease Control and Preventions (CDC- the nation's leading science-based, data-driven, service organization that protects the public's health) guidelines by failing to: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to promptly (punctually [with little or no delay]) notify the responsible party (RP) for one of five sampled residents (Resident 3) who experienced a change of condition (COC- a sudden clinically important deviation from a resident/patient's baseline in physical, behavioral, or functional domains), as indicated in the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 2 notified Resident 3's RP (RP 1), promptly when LVN 2 noted bruising (mark on the skin caused by blood trapped under the surface because of injury to small blood vessels but does not break the skin) to Resident 3's right knee on 7/15/2024 at 2:34 pm. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to report an injury of unknown origin/source (the source of the injury was not observed by any person and could not be explained by the resident) immediately, but not later than 24 hours to the Administrator (ADM) of the facility, the California Department of Public Health (CDPH), local law enforcement, and Ombudsman (resident advocate who investigates, reports, and helps settle complaints) as indicated in the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating, for one of five sampled residents (Resident 3). This failure violated the mandated reporting timeframe and had the potential to compromise Resident 3's safety and could result in further injuries potentially related to abuse for Resident 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) titled, Nail Care, for two of five sampled residents (Residents 1 and 3) by failing to: 1. Ensure assigned Certified Nursing Assistants (CNAs) trimmed and cleaned the fingernails of Resident 1 who required substantial/maximal assistance (helper did more than half the effort, helper lifted or held trunk or limbs and provided more than half the effort) with personal hygiene. 2. Ensure assigned CNAs notified assigned Licensed Vocational Nurses (LVNs) regarding Resident 1's and Resident 3's long and overgrown toenails. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide copies of Resident's medical record requested from the Representing Party (RP) for one of three residents (Resident 1). This failure violated Resident 1's right and resulted in Resident 1's PR received Resident 1's medical record six days late.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's Advance Directives (AD, a written preferences regarding treatment options, a process of communication between individuals and their healthcare agents to understand, reflect on, discuss, and plan for future healthcare decisions for a time when individuals are not able to make their own healthcare decisions) and Consent for Medical Treatment (CMT, permission given before a resident receive any type of medical treatment, test or examination) were discussed and written information were provided to the residents and/or responsible parties for three of four sampled residents selected for advance directives care area (Residents 18, 192 and 35) in accordance with the facility's policy and procedure. [...]

Inspectors wroteDuring observation, interview, and record review, the facility failed to provide care and services to promote the healing of pressure ulcers (lesion/wound caused by unrelieved pressure that results in damage of underlying tissue) for three of four sampled residents (Residents 78, 241 and 35.) with existing pressure ulcers by failing to: a. Turn and reposition Residents 78 and 241 with an existing Stage 4 pressure ulcer (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle). Residents 78 and Resident 241 required assistance with turning and repositioning. b. Ensure Resident 35's Low Air Loss Mattress (LAL- a bed mattress designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) static setting was turned off while Resident 35 was lying in bed. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all nursing staff possess the competencies (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles successfully) and skill sets necessary to meet the residents' needs safely when the facility failed to: a. Ensure the competency skills evaluation included pressure ulcer prevention and management for two of two sampled Certified Nursing Assistants (CNAs 3 and 4). b. Ensure all direct care staff received in-service regarding pressure ulcer prevention and management that would include turning and repositioning and the operation of the low air loss mattress (LAL- a bed mattress designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown.)

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide safe and sanitary environment to help prevent the development and transmission of communicable diseases (one that is spread from one person to another) for eight of eight sampled residents (Residents 191, 39, 38, 32, 30, 70, 8, and 2) selected for infection control care area, by failing to: a. [...]

Inspectors wroteBased on interview and record review, Resident 33's notice of Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) of non-coverage did not have documented evidence of an informed decision from Resident 33's responsible party to pay for non-covered services after Resident 33 was discharged from Medicare Part A and Resident 33 continue to reside in the facility for one of one sampled resident (Resident 33). This deficient practice placed Resident 33 at risk for payment of out-of-pocket costs for non-coverage services while in the facility.

Inspectors wroteBased on observation, interview, and record review, the certified nurse assistant (CNA) failed to protect the resident's rights by not closing the privacy curtain to ensure the resident was not visually exposed to the roommate while the CNA was cleaning the resident for one of one sampled resident (Resident 34) selected for privacy care area. This failure resulted in the violation of the resident's right for privacy.

Inspectors wroteBased on observation, interview and record review, the facility failed to assess and monitor the presence of white sediments (visible particles in the urine that could indicate infection or dehydration [fluid deficit]) in the urine for one of one sampled residents (Resident 58) with indwelling catheter (foley catheter [FC] - a tube inserted in the bladder to drain urine into a drainage bag) as indicated in the facility's policy and procedure, titled Foley Catheter Guidelines for Preventing Catheter Associated Urinary Tract Infections (CAUTI's) and the resident's care plan. This deficient practice had the potential for Resident 58 to receive no care or delayed care and treatment for urinary tract infection (UTI, condition in which bacteria invade and grow in any part the urinary system).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary care and services for gastrostomy tube (GT, a tube inserted through the abdomen that delivers nutrition directly to the stomach) site as ordered by the physician and as indicated in the plan of care for one of one sampled resident (Resident 26) selected for tube feeding care area. This failure had the potential for complications related to tube feedings for Resident 26.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the dialysis (procedure to remove wastes or toxins from the blood and adjust fluid and electrolyte imbalances) emergency kit was readily available at the bedside for one of one sampled resident (Resident 51). This deficient practice had the potential for adverse consequences in the event of emergency bleeding from the dialysis access site for Resident 51.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 33) on psychotropic drugs (any drug that affects brain activities associated with mood, emotions, and behavior) was free from unnecessary medications by failing to ensure staff attempted a gradual dose reduction ([GDR] the stepwise tapering of a dose to determine if symptoms, condition, or risks can be managed by a lower dose or if the dose or medication can be discontinued) of Resident 33's Quetiapine Fumarate ([antipsychotic drug] a drug use to treat symptoms of psychosis or disconnection from reality) 25 milligram ([mg] unit of measurement) since ordered on 9/9/2022. This deficient practice placed Resident 33 at risk for adverse drug reaction (a harmful and unintended response to a medicine).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure its binding arbitration agreements included selection of a neutral arbitrator and a venue convenient to both facility and resident/resident responsible party for two of two sampled residents (Residents 33 and 50). This deficient practice placed Residents 33 and 50 at risk for an unjust arbitration and delayed arbitration hearing in an event of an arbitration dispute.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its abuse Policy and Procedure for Abuse Allegation Reporting for two of three sampled residents (Residents 1 and 3) by failing to: 1. Report an incident of injury of unknown origin which occurred on 12/25/23 to Resident 1 to the California Department of Public Health (CDPH) Licensing and Certification (State Agency) within two hours. 2. Report an incident of injury of unknown origin which occurred on 12/24/23 to Resident 3 to the California Department of Public Health Licensing and Certification. These deficient practices had the potential for delayed abuse investigation for Residents 1 and 3.

Inspectors wroteBased on interview and record review, the facility failed to provide nursing care and services for one of five sampled residents (Resident 1) by failing to: 1. Ensure Registered Nurse (RN) 2 reconciled (comparing a resident's medication orders to the medications he/she has been taking to avoid medication errors) Resident 1's insulin [medication used to help the body turn food into energy and control blood-sugar/glucose (BS) levels] per Resident 1's physician order for insulin aspart (rapid-acting insulin that helps lower mealtime blood-sugar spikes) per sliding scale (varies the dose of insulin based on the BS level prior to insulin administration, the higher the BS level, the higher the insulin dose) when Resident 1 was readmitted from General Acute Care Hospital (GACH) 1 to the facility on [DATE]. 2. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) were followed in accordance with the facility's policy and procedures by failing to: 1. Ensure three of five sampled staff (Certified Nurse Assistants [CNA] 1, Housekeeping Staff (HS) 1, and CNA 2) wore appropriate personal protective equipment (PPE- equipment worn to minimize exposure to a variety of hazards) when entering residents' room who were on transmission-based precautions (TBP- used when a resident is suspected or known to be infected with infectious agents, and require additional control measures to prevent transmission). 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Census and Direct Care Service Hours Per Patient Day (DHPPD) and Staffing Posting were updated and posted daily at the beginning of each shift for in accordance with the facility ' s policy and procedures for two of three sampled stations. This failure resulted in the facility DHPPD/Staffing Posting not being updated and accurate for residents and visitors in a readable format on 9/11/2023.