Crystal Cove Care Center

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to follow the physician's orders for one of five final sampled residents (Resident 12) reviewed for unnecessary medications and failed to follow safe medication storage and destruction practices for used controlled medicated patches. * Resident 12's blood pressure medications were not administered as ordered. * The DON did not wear gloves when handling used fentanyl patches medication. Additionally, the fentanyl patches medication were stored in open packages, there were missing patches, and the accompanying narcotic sheet counts were not readily available. These failures put the resident at risk a negative outcome, and potentially exposing staff to inadvertent exposure to a controlled medication.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure processes for labeling and storing biologicals were maintained. * Resident's 28 Liraglutide (insulin) pen injector label showed to administer 1.8 mg while the physician's order showed to administer 1.2 mg of Liraglutide. * The enteral feeding storage area did not have a thermometer or temperature log to ensure the enteral feedings temperatures were being maintained at room temperature. These failures had the potential for the residents to not receive the correct dosage of insulin and for enteral feedings to not be stored at appropriate temperatures, potentially compromising resident safety and care.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitation guidelines were followed. * The facility failed to ensure food preparation equipment was air dried. This failure had the potential to cause foodborne illnesses in a medically vulnerable resident population for 77 out of 82 residents that consumed food prepared in the kitchen.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure food brought to the facility from outside sources for the resident consumption was properly stored. * The facility failed to ensure multiple food items were labeled, dated, and discarded before the use-by date. These failures had the potential to expose the residents who received food brought from the outside to food borne illnesses.

Inspectors wroteBased on observation, interview, and the facility P&P review, the facility failed to properly dispose of multiple items when they were observed in the dumpster area. * The facility failed to ensure four mattress covers, a bed frame, a laundry cart, a small table with a machine for a special mattress and linen stored on top, and a wooden frame were properly disposed. This failure had the potential to harbor pests or rodents which carry diseases.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the resident's medical record was accurate for three of 18 final sampled residents (Residents 1, 12, and 27) and one nonsampled resident (Resident 32). * Resident 1's post fall and fall risk assessments were inaccurate for recent falls.* Resident 12's POLST had an inaccurate date for the resident's current Advance Directive.* Resident 32's medical record failed to include the resident's decreased functional ability. * Resident 27's MAR for monitoring, pain scale, side effect monitoring, and anticoagulant monitoring was incomplete and/or inaccurate. These failures resulted in incomplete and inaccurate medical records, which have the potential to negatively impact continuity of care and clinical decision making.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the infection control practices were followed. * LVN 4 failed to perform hand hygiene after touching the trash receptacle, then touching and pouring water from a water pitcher, and then pouring medications into medication cups for a resident. * A GT syringe was not rinsed after medication administration. The syringe was observed with yellow particles near the tip of syringe. * Resident 84's infection surveillance tool inaccurately showed the resident met criteria for a UTI. * The facility failed to ensure Resident 75's urinary drainage bag was not on the floor. * The facility failed to ensure staff offered Resident 95 to perform hand hygiene before receiving a meal. [...]

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to report an abuse allegation for one of 18 final sampled residents (Resident 105) timely. * Resident 105 reported to the Case Manager that the night shift staff came to the resident and made the resident feel uncomfortable. Resident 105 further reported to the ADON that the night nurse was unpleasant and rude. This failure placed the resident at risk for potential ongoing abuse, delayed thorough investigation, a potential lack of protection of the resident and other residents from potential abuse, and resulted in a delay for CDPH and local law enforcement intervention.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to thoroughly investigate an abuse allegation for one of 18 final sampled residents (Resident 105). * Resident 105 reported a night shift staff came to the resident and made the resident feel uncomfortable, to the Case Manager. Resident 105 further reported the night nurse was unpleasant and was rude, to the ADON. This failure placed the resident at risk for potential ongoing abuse, delayed thorough investigation and potential lack of protection of the resident and other residents from potential abuse.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the plan of care for one of 18 final sampled residents (Resident 98) was followed and revised. * Resident 98's interventions for keeping the bed in a low position was not followed. * Resident 98's plan of care was not revised to show interventions for Resident 98 raising the bed on her own, per staff. These failures posed the risk of not providing appropriate care for Resident 98.

Inspectors wroteBased on interview, medical record review, and facility P&P review the facility failed to provide the necessary care and services to ensure two of 18 final sampled residents (Residents 1 and 14) attained and maintained their highest practicable physical well-being. * The facility failed to ensure Resident 1's post fall neurological assessment was completed as scheduled. * The facility failed to ensure the heparin and insulin injection sites were rotated for Resident 14. These failures had the potential to result in inaccurate assessment, altered medication effectiveness, impaired insulin absorption and tissue damage which could lead to negative residents outcomes.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure one of three final sampled residents (Resident 98) reviewed for accident hazards remained free of accidents. * Resident 98's bed was not kept in a low position. This failure posed the risk of Resident 98 suffering serious injuries from any future falls.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the nutritional needs were met for one of one non-sampled resident (Resident 30) reviewed for nutrition. * The facility failed to ensure Resident 30 was offered an alternative meal item when Resident 30 consumed around 25% of her meal tray. This failure had the potential to compromise Resident 30's nutritional status.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure appropriate care and services for the use of the GT for one of one final sampled resident reviewed for tube feeding (Resident 4). * The facility failed to ensure Resident 4's head of the bed was elevated at a 30-degree angle or above during the enteral feeding via the GT. This failure posed the risk for complications related to use of the GT for Resident 4.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the respiratory care and services were provided in accordance with professional standards for one of one final sampled resident (Resident 5) reviewed for respiratory care. * The facility failed to ensure Resident 5's nebulizer mask was stored in a bag when not in use. This failure had the potential for the resident to receive inadequate respiratory care and increased risk for infection.

Inspectors wroteBased on observations, interviews, and a review of Title 21, the facility failed to provide documented evidence demonstrating compliance with State law. * There were used fentanyl patches (a medication used in the management and treatment of chronic pain) not stored and destroyed as per federal regulations related to the fentanyl medication use. This failure posed the risk of diversion and inappropriate storage of the used fentanyl patches.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to implement their antibiotic stewardship program to show timely physician notification for one nonsampled resident (Resident 84) who received antibiotics for an infection that did not meet the facility's infection surveillance tools criteria. * The facility failed to ensure Resident 84's symptoms met the criteria for a UTI, notify the physician the infection did not meet the criteria, and reassess the need for continued antibiotic therapy. This failure had the potential for the resident being on unnecessary antibiotic therapy potentially resulting in MDRO's.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the confidential personal and health information of the residents in the facility were protected. * The facility failed to ensure a non-employee was not permitted inside the medical records office. This failure had the potential for the residents' personal and health information to be accessed by an unauthorized person.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to implement the infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of diseases and infections. * RN 1 and LVN 2 failed to wear a gown during the wound care treatment for Resident 3, who had a Stage 3 pressure injury (a full-thickness skin loss where fat tissue is visible, but the bone, tendon, or muscle are not exposed). In addition, there was no EBP signage near the resident's room doorway or bedside to alert the facility staff and/or visitors of the precautions. These failures posed the risk of potential for cross-contamination and spread of infectious organisms in the facility.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the discharge medication list was appropriate for one of two sampled residents (Resident 3) reviewed for discharge. * Resident 3's discharge medication list did not include the Verapamil (blood pressure medication), Ambien (medication used to treat insomnia) and oxycodone-acetaminophen (pain reliever medication). This failure had the potential for the resident not receiving appropriate care and proper medication management after the discharge.

Inspectors wroteBased on interview and medical record review, the facility failed to provide the necessary care and services to ensure one of eight sampled residents (Resident 3) attained and maintained the highest practicable physical well-being * The facility failed to provide documented evidence Resident 3's physician was notified of Resident 3's abnormal blood pressure. Additionally, Resident 3's blood pressure was not retaken when it was documented it was above normal. These failures had the potential to negatively impact the resident.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the pharmaceutical services were provided for two of eight sampled residents (Residents 3 and 4) reviewed for medications. * Resident 3's Verapamil (blood pressure medication) and Ambien (medication used to treat insomnia) were not available for Resident 3 to take. * The controlled medication count sheets for Resident 4's oxycodone were not on file. These failures had the potential for the residents to not receive appropriate care and proper medication management.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure infection control practices were maintained for one of eight sampled residents (Resident 2) reviewed for infection control. * LVN 1's shoe was touching Resident 2's suprapubic catheter urine drainage bag. * LVN 1 failed to perform hand hygiene after removing dirty gloves and before putting on clean gloves. * Resident 2's suprapubic catheter urine drainage bag was touching the floor. These failures had the potential for cross-contamination and spread of infectious organisms in the facility.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the appropriate pain management for three of three sampled residents (Residents 1, 2, and 3). * The facility failed to accurately document the monitoring of pain levels for Residents 1, 2, and 3 and administer the pain medications according to the physician's orders. This failure had the potential to put Residents 1, 2, and 3 at risk for ineffective pain management.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services for one of six sampled residents (Resident 1). * The facility failed to ensure the proper interventions were implemented when Resident 1 did not have a BM for more than three days. This failure had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the care plan reflected the individual care needs for one of six sampled residents (Resident 1). * The facility failed to develop additional or different interventions in the care plan to reduce the risk of falls for Resident 1. This failure posed the risk of not providing the appropriate, consistent, and resident-centered care to the resident.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure the proper safe storage of drugs for one of six sampled residents (Resident 6). * LVN 1 left three medications inside a clear cup unattended on Resident 6's bedside table. This failure posed the risk of other residents, visitors or unauthorized facility staff gaining access to the medication.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of two sampled residents (Resident 1) was provided the non-pharmacological interventions for the use of psychotropic medication (medication that affects the mind, emotions, and behavior). This failure had the potential to result in the unnecessary use of psychotropic medications for Resident 1.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the information regarding the rights to formulate the advance directives and/or failed to obtain and maintain the copies of advance directives for two of 22 final sampled residents (Residents 10 and 586). These failures had the potential for the residents' decisions regarding their healthcare and treatment options not being honored.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure two of 22 final sampled residents (Residents 45 and 336) attained and maintained their highest practicable physical well-being. * The facility failed to monitor Resident 336's pacemaker. In addition, the facility failed to ensure Resident 336's skin assessments were accurate and complete. Furthermore, the facility failed to monitor Resident 336 after the removal of the staples on her back, obtain the physician's order before applying the Steri-Strips to Resident 336's surgical site, and develop a plan of care to monitor the surgical site and address the removal of the staples. * The facility failed to ensure the laboratory tests for CBC, Chem 7 blood panel and magnesium level ordered for Resident 45 were completed. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development of pressure injuries for one of two final sampled residents reviewed for high risk of developing pressure injuries (Resident 40). * The facility failed to ensure Resident 40's turning and repositioning interventions were implemented to prevent the development of the pressure injuries. This failure had the potential for the resident to develop pressure injuries or worsening of the existing pressure injuries.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the appropriate care and services to prevent UTIs for one of three final sampled residents (Resident 336) reviewed for the use of indwelling urinary catheter. * The facility failed to ensure the indwelling urinary catheter care was provided to Resident 336. In addition, the facility failed to monitor Resident 336's urinary output as per the resident's plan of care and provide the bladder training for Resident 336. These failures posed the risk for Resident 336 to develop CAUTI and negatively impact Resident 336's well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to monitor the fluid intake for one of one final sampled resident (Resident 45) reviewed for hydration status. * The facility failed to ensure Resident 45's fluid intake from the dietary department and the total daily fluid intake were monitored. This failure had the potential for Resident 45 to have fluid overload, which had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on observation, interview, medical record review and facility P&P review, the facility failed to provide the necessary respiratory care and services for three of three final sampled residents (Residents 67, 336, and 686) reviewed for the respiratory care. * The facility failed to obtain a physician's order prior to the oxygen administration for Resident 686. * The facility failed to obtain a physician's order prior to the oxygen administration for Resident 336. The facility failed to place an Oxygen In Use sign outside the door of Resident 336's room as per the facility's P&P. In addition, the facility failed to develop a care plan problem to address Resident 336's oxygen use. Furthermore, the facility failed to administer oxygen as per the physician's order to Resident 336. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the dialysis care was provided for one of two final sampled residents (Resident 70) reviewed for dialysis as evidenced by: * The facility failed to ensure the dialysis emergency kit was maintained at the bedside for Resident 70. In addition, the facility failed to ensure Resident 70's dialysis access site was assessed and monitored appropriately and consistently. The licensed staff failed to consistently assess Resident 70's dialysis access site prior to the resident being transported to the dialysis treatment center and upon returning from the dialysis center. In addition, the licensed staff documented Resident 70's dialysis access type as either catheter or left blank, instead of permacath. [...]

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the competency of two of two licensed nurses (LVN 12 and the ADON) interviewed regarding bladder training and failed to ensure the annual performance evaluation was conducted for one of three licensed nurses (LVN 5) reviewed for the annual performance evaluation. * The facility failed to ensure LVN 12 and the ADON were able to demonstrate their competency on the bladder training for a resident with an indwelling urinary catheter. * The facility failed to provide the training materials used for the in-service trainings provided to the facility staff. * The facility failed to ensure the annual performance evaluation was completed for LVN 5. These failures had the potential to put the residents at risk for care not being provided in a safe and competent manner. 1. [...]

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure one of five final sampled residents (Resident 67) reviewed for unnecessary drugs were free from unnessary drugs. * Resident 67 had duplicate medication orders with different dosages. This failure posed the risk of medication errors.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure two of five final sampled residents (Residents 1 and 336) reviewed for unnecessary medications was free from the unnecessary psychotropic medication. * The facility failed to ensure the informed consent for zolpidem (hypnotic medication) was signed by the physician. In addition, the facility failed to ensure the monitoring for hours of sleep related to the use of zolpidem matched the documentation of the episode when Resident 336 was unable to sleep. * The facility failed to ensure the informed consent for Resident 1's clonazepam (antianxiety medication) medication was renewed and the consent was obtained from the responsible party and signed by the physician. [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the medications were stored safely, securely and properly labeled. * The facility failed to ensure the single use dressings and discontinued topical medication were removed and discarded from the treatment cart. Furthermore, the facility failed to ensure the treatment cart was clean. * The facility failed to ensure the expired Covid testing kits were discarded. * The facility failed to ensure a medication with white pasty cream and a bottle of Adapt stoma powder (powder used to absorb moisture from broken skin around the stoma, which allows for better barrier adhesion to help protect the skin) were not kept at Resident 54's bedside. These failures had the potential to negatively impact the residents' wellbeing.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the kitchen utensils were clean and free of food particle or residue. * The facility failed to ensure the kitchen utensil was in good condition. These failures had the potential for cross contamination and foodborne illnesses to the residents consuming the foods prepared in the facility's kitchen.

Inspectors wrote7. Medical record review for Resident 336 was initiated on 2/18/25. Resident 336 was admitted to the facility on [DATE]. Review of Resident 336's POLST dated 2/14/25, showed a different resident name and the wrong birthdate. Review of Resident 336's Informed Consent - Immunization (Updated) - V2 dated 2/14/25, for influenza vaccine, showed a different resident name. Review of Resident 336's Informed Consent - Immunization (Updated) - V2 dated 2/14/25, for pneumonia vaccine, showed a different resident name. Review of Resident 336's Informed Consent - Immunization (Updated) - V2 dated 2/14/25, for Covid-19 vaccine, showed a different resident name. Review of Resident 336's Consent to Treat dated 2/14/25 showed a different resident name. On 2/21/25 at 1338 hours, an interview and concurrent medical record review for Resident 336 was conducted with RN 4. RN 4 verified the above findings. [...]

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to maintain the infection control program designed to help prevent the development and transmission of diseases and infections. * The facility failed to implement their infection control surveillance program for November 2024, December 2024, and January 2025. The facility failed to correctly identify the HAIs and CAIs. The facility failed to conduct an accurate infection surveillance as per the McGeer criteria. The facility failed to ensure the residents infections were mapped and tracked. In addtion, the facility failed to ensure the infection control data presented to the infection control meeting was accurate and complete. * The facility failed to ensure the clean personal clothing and linen cart were covered during transportation. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the privacy was provided for one of five final sampled residents (Resident 40) observed for medication administration. * The privacy curtain was not pulled to provide privacy during the GT medication administration for Resident 40. This failure had the potential to negatively affect the dignity of the residents and violate the residents' right to privacy.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the personal belonging inventory process were completed for one of 22 final sampled residents (Resident 336). * The facility failed to ensure a copy of Resident 10's personal inventory list was provided to the resident upon admission. This failure had the potential for the resident's personal belongings not being accounted for accurately.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the resident or the residents' representative was provided with a written or verbal notice of the facility's bed hold (holding or reserving a resident's bed while the resident in the acute care hospital) policy upon transfer to the acute care hospital for one of three residents (Resident 85) reviewed for closed records. This failure had the potential for the resident and the residents' representative to be unaware of their rights to return to the facility following a hospitalization.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the plan of care for one of 22 final sampled residents (Resident 5) was revised to address the resident's specific care needs when the resident refused to wear the sling on RUE as ordered by the physician. This failure posed the risk of not providing the appropriate, consistent, and individualized care to the resident.

Inspectors wroteBased on interview, facility document review, and facility P&P review, the facility failed to ensure the performance evaluations were completed every 12 months for one of two CNAs' (CNA 7) employee files reviewed. This failure had the potential for the staff to not maintain competencies to provide the residents with needed and appropriate care and services.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the resident's specimen refrigerator was in safe operating condition. * The facility failed to ensure the specimen refrigerator was maintained at the temperature range of 36-46 degrees F and the freezer compartment of the specimen refrigerator was free of ice buildup. These failures had the potential to affect the resident's health due to the refrigerator not being maintaned.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive care plan was developed and implemented for one of two sampled residents (Resident 1). * The facility failed to implement Resident 1's care plan for the use of dental appliances (dentures) during meals and for the coordination of a dental consult, to assist Resident 1 with obtaining lower dentures, after his readmission to the facility. * The facility failed to develop a comprehensive care plan to address Resident 1's hard of hearing status. These failures placed the resident at risk of not being provided appropriate, consistent, and individualized care.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide dental services to meet the needs of one of two sampled residents (Resident 1). * The facility failed to assist Resident 1 with obtaining the lower dentures since his readmission to the facility. * The facility had failed to conduct a loss or theft investigation specific to Resident 1's lower dentures and failed to coordinate a dental consult for Resident 1. These failures had the potential to negatively affect Resident 1's well-being.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the necessary care and treatment related to oxygen administration for one of three final sampled residents (Resident 2). * The facility failed to administer the oxygen to Resident 2 as ordered by the physician. This failure posed the risk of the resident developing complications due to inadequate oxygen therapy.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the home health services were in place before the resident was discharged home from the facility for one of two sampled residents (Resident 2). * Resident 2 was discharged home with an order for home health services, which included registered nursing and physical therapy. However, the facility failed to ensure home health services were in place, prior to Resident 2 being discharged home. This failure posed the risk for an unsafe transition from the facility to the home setting.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for one of two sampled residents (Resident 2). * The facility failed to obtain a physician's order for the use of an intermittent urinary catheter (in an attempt to obtain a urine specimen) for Resident 2. This failure posed the risk for the unnecessary use of a urinary catheter which had the potential for negative health outcomes. * The facility failed to ensure Resident 2's abductor pillow was utilized properly. Resident 2 recently had undergone hip surgery. Resident 2's plan of care included the use of an abductor pillow, status post-surgery, while in bed. Resident 2 was observed lying in bed without the abductor pillow straps attached to Resident 2's legs. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the pain assessment was conducted in accordance with the facility's P&P, after a resident complained of pain for one of two sampled residents (Resident 1). * Resident 1 refused to undergo dialysis and claimed he was in pain. The facility failed to conduct a pain assessment specific to Resident 1's complaint of pain. This failure posed the risk to not identify, address, and treat Resident 1's underlying cause of pain, which posed the risk for negative health outcomes.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of two sampled residents (Resident 1) was free from significant medication errors. * Resident 1's written order for clonidine was incorrectly entered into Resident 1's electronic medical record. As a result, Resident 1 did not receive 34 doses of clonidine as ordered. This failure posed the risk for negative health outcomes for Resident 1.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure a laboratory test was performed as ordered by the physician, for one of two sampled residents (Resident 1). * Resident 1's physician ordered a lipase (enzyme secreted by the pancreas) level; however, the facility failed to perform the laboratory test. This failure had the potential for a delay in necessary treatment and services for Resident 1.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the medical record was accurate for one of two sampled residents (Resident 1). * Resident 1 had an abdominal ultrasound performed on 10/9/22;however, the licensed nurse documented Resident 1 had a KUB performed on 10/9/22. This failure had the potential for the resident's care needs not being met as the medical information was inaccurate.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure proper labeling and dating of opened food items in the refrigerator. * The facility failed to ensure the bin containing kitchen utensils was clean. * The facility failed to ensure the handles of the ladles were not melted. * The facility failed to ensure turkey baster was clean. * The facility failed to ensure plate warmer was clean. * The facility failed to ensure the glaze on the handles of the adaptive utensils (specialized forks, spoons with built-up handles to help people with disabilities to dine independently) was not worn off. [...]

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to implement their infection control surveillance program in accordance with the facility's P&P and failed to maintain the infection practices to help prevent the development and transmission of diseases and infection. * The facility failed to maintain an accurate infection surveillance program for April, May, and July 2023 when: - the facility failed to ensure an Infection Prevention and Surveillance Log was completed for April 2023. - the facility failed to ensure a summarized Monthly Infection Control Surveillance was completed for May 2023. - the facility failed to ensure all McGeer's Criteria were completed for July 2023. [...]

Inspectors wroteBased on interview, facility document, and facility P&P review, the facility failed to implement the antibiotic stewardship program. The facility failed to ensure two of 20 final sampled residents (Residents 14 and 488) were accurately and timely reviewed for the appropriate use of antibiotics. This failure had the potential for inappropriate use and increased risk of drug resistant organisms.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to maintain the essential equipment used to prepare, serve, and store food in the facility. * The facility failed to ensure Freezer #1 was functioning properly to maintain the required temperature of 0 degrees F or lower. * The facility failed to ensure the ice machine was not leaking. * The facility failed to ensure the microwave used to warm the residents' foods was free from rust. These failures had the potential for equipment not functioning in the way they were intended and in turn cause contamination of food, leading to food-borne illnesses for the residents who received food from the kitchen.

Inspectors wroteBased on interview, medical record, facility P&P review, and facility document review, the facility failed to ensure the staff provided care and promoted dignity and respect for one nonsampled resident (Resident 3). * CNA 1 was observed standing over Resident 3 while assisting the resident with meals. This failure had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of 20 final sampled residents (Resident 13) was given the opportunity to participate in the care plan conferences. This had the potential for Resident 13 to not be able to choose treatments options and make decisions in care planning.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the personal belongings were returned timely during and after discharge for one of 20 final sampled residents (Resident 441). * Resident 441's personal medications (a bottle of multivitamins and a bottle of vitamin D) were not returned timely by the facility during discharge and after discharge. This had the potential for Resident 441's personal belongings being lost.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to obtain and maintain the copies of advance directives (legal document that states a person's wishes about receiving medical care if that person is no longer able to make medical decisions) and failed to provide the information regarding the rights to formulate the advance directives for three of 12 final sampled residents (Residents 48, 72, and 539). These failures had the potential for the residents' decisions regarding their healthcare and treatment options not being honored.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the information on how to file a grievance was provided to one of 12 final sampled residents (Resident 72) and four nonsampled residents (Resident 7, 11, 41, and 60) participated in the Resident Council and failed to ensure the residents' grievances were resolved by the facility. These failures had the potential to cause the residents feeling hopeless and may negatively affect their emotional well-being.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to report an allegation of resident-to-resident altercation between one of 20 final sampled residents (Resident 13) and one nonsampled resident (Resident 50) to the CDPH L&C and LTC Ombudsman Programs as per the facility's P&P. This failure had the potential for the residents to be vulnerable for further abuse.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the physician and resident's representative were notified, changes in the care plan approaches were completed, and continued monitoring was performed for one of 20 final sampled residents (Resident 13) and one nonsampled resident (Resident 50) for an allegation of resident-to-resident altercation as per the facility's P&P. * Resident 13 claimed he was allegedly punched in the face seven times by Resident 50. This failure had the potential for further resident abuse to occur and put other residents at risk for abuse.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure two of 20 final sampled residents (Residents 8 and 13) received the accurate MDS assessments. * Resident 13 stated he was legally blind, unable to read fine prints, and was not on a physician's prescribed weight gain regimen. However, the MDS dated [DATE], showed Resident 13 had adequate vision and was on physician prescribed weight gain. * Resident 8's Annual MDS failed to accurately reflect the resident's fall with major injury. These failures had the potential of not meeting the residents' care needs.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the comprehensive plan of care for one of 20 final sampled residents (Resident 8) was revised to reflect the resident's current care needs and interventions. * Resident 8's plan of care showed a care plan problem dated 4/22/22, addressing Resident 8's at risk for falls and use of the bilateral floor mats as one of the interventions. The physician ordered to discontinue the bilateral floor mats on 7/15/22. Resident 8's care plan was not revised to reflect the physician's order dated 7/15/22, to discontinue the bilateral floor mats. This failure posed the risk of not providing Resident 8 with an individualized and person-centered care.

Inspectors wroteBased on interview and medical record review, the facility failed to provide the necessary care and services to ensure two of 20 final sampled residents (Residents 34 and 48) attained and maintained their highest practicable well-being. * The facility failed to coordinate the care of Resident 48 with the contracted hospice. The hospice calendar and the sign-in/out forms did not show skilled nursing and CHHA visits provided as per the physician's orders. In addition, the medication profile list, nursing clinical notes, and hospice aide notes were not updated. Furthermore, a hospice packet containing the Continuous Care Note, Continuous Care Documentation, Continuous Care Initiation Sheet, Hospice Aide Care Plan/Note, Plan of Care, Pain Inventory Scale, and Medication List were blank. [...]

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services to prevent accidents for one of 20 final sampled residents (Resident 8). * The CNA improperly turned Resident 8 to her left side while in bed during incontinence care, and Resident 8 fell off the bed. As a result, Resident 8 sustained a fracture to the right humerus. * The facility failed to ensure the recommendation to apply the ice pack to the right shoulder area from Resident 8's orthopedic appointment was verified and followed.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the safe respiratory care for one of 20 sampled residents (Resident 17). * The facility failed to ensure Resident 17's C-PAP (continuous positive airway pressure) machine was cleaned as per the manufacturer's user cleaning guidelines. This failure had the potential to adversely affect the health and well-being Resident 17 and posed the risk for equipment contamination and respiratory complications.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the dialysis care was provided for one of 20 final sampled residents (Resident 34) as evidenced by: * The facility failed to ensure Resident 34's dialysis access site was assessed and monitored appropriately and consistently. The licensed staff failed to consistently assess Resident 34's dialysis access site prior to the resident being transported to the dialysis and upon return from the dialysis clinic. In addition, the licensed staff documented Resident 34's dialysis access type as AV fistula (arteriovenous fistula, created by connecting an artery and a vein directly), instead of AV Graft (arteriovenous graft shunt, created by inserting a synthetic tube between an artery and a vein). [...]

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the pharmaceutical services to ensure accurate reconciliation, administration, and disposal of medications as evidenced by: * The facility failed to ensure non-controlled medications were discarded by two licensed nurses. * The facility failed to ensure administration of the controlled medications for one of nonsampled (Resident 539) was accurately documented to ensure accurate reconciliation and to prevent the medication administration errors. These failures had the potential for medication administration error, inaccurate reconciliation, and drug diversion (illegal distribution or abuse of prescription drugs or their use for unintended purposes) of controlled medications.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of 20 final sampled residents (Residents 28 and 66) were free from the unnecessary medications. * The facility failed to accurately document the monitoring for signs and symptoms of bleeding related to Resident 28's use of apixaban (anticoagulant medication used to prevent blood clots). * The facility failed to monitor Resident 28's orthostatic blood pressure (a form of low blood pressure that happens when standing after sitting or lying down) * The facility failed to ensure accurately documenting the monitoring of the side effects related to Resident 66's use of apixaban (anticoagulant medication used to prevent blood clots). [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure three of 20 final sampled residents (Residents 8 and 34) were free from unnecessary psychotropic medications (any drug which affects brain activities associated with mental processes and behavior). * The facility failed to ensure the number of behavioral episodes related to the use of alprazolam was monitored per shift as per the physician's order. Furthermore, the facility failed to ensure the monthly behavior summary related to the use of zolpidem was completed for July 2023 for Resident 34. * The facility failed to consistently monitor the behavior manifestation, and accurately document the monthly behavioral episodes related to the use of Trazodone for Resident 8. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. * The facility's medication error rate was 6.67%. Two of three licensed nurses observed (LVNs 3 and 4) were found to have made errors during the medication administration observation. * LVN 3 failed to administer the correct medication as ordered by the physician for Resident 17. * LVN 4 failed to administer one medication as ordered by the physician for Resident 640. These failures had the potential to negatively affect the residents' health.

Inspectors wroteBased on observation, interview, medical records, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure proper storage, labeling, and disposal medications. * The facility failed to ensure an opened Aplisol Injection tuberculin purified protein derivative (aids in the diagnosis of tuberculosis) vial was labeled with opened date. * The facility failed to ensure the opened insulin vials from the insulin emergency kit was labeled with opened date and the insulin emergency kit was replaced. * The facility failed to ensure proper disposal of the expired Covid swab test supplies. * The facility failed to ensure an unopened pen of Insulin Lispro (fast acting insulin) was refrigerated. These failures had the potential to negatively impact the residents' well-being and had the potential for the medications to loss the stability and effectiveness.

Inspectors wroteBased on observation, interview, facility document review, facility P&P review, and manufacturer's instruction manual review, the facility failed to ensure the kitchen staff had the appropriate skill set to safely perform the daily operation of the Food and Nutrition Services Department as evidenced by: * The Dietary Director/RD was unable to demonstrate the correct procedure of the thermometer calibration. This had the potential to lead to foodborne illnesses in a highly susceptible population of residents who received food prepared in the kitchen.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the menus were followed. * A chicken broth was used instead of water during the pureed bread preparation. This failure placed the residents receiving pureed diet at risk for not receiving the menu as planned.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the food served was palatable. * The pureed bread was sticky in texture. * The garlic bread was chewy in texture. These failures had the potential to impact the residents' nutritional status.

Inspectors wroteBased on observation and interview, the facility failed to ensure the food preference was honored for one nonsampled resident (Resident 12). * Resident 12 disliked wheat bread but was served a ham sandwich with wheat bread on his lunch tray. This had the potential to negatively affect the resident's food intake and nutritional status.