Deerbrook Skilled Nursing and Rehab Center

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents were free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 6 residents (Resident CR# 1) reviewed for neglect. The facility failed to develop and implement an effective system to accurately identify, assess, and treat residents with wounds when CR#1 had wounds (unstageable DTI of the right, medial heel, stage 4 pressure wound of the left hip, stage 3 pressure wound of the right sacrum, and unstageable [due to necrosis] scrotum) that were not identified upon initial assessment, reported to physician, or treated for 12 days which resulted in worsening of wounds and development of new wounds. The facility failed to notify the physician immediately when there were no orders for the skin injuries noted upon admission on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 6 residents (Resident CR# 1) reviewed for pressure ulcers.1. The facility failed to identify and provide wound treatment from 3/13/26 to 3/25/26 for CR #1 who experienced a decrease in skin integrity to the left hip that resulted in a stage 4 pressure wound, stage 3 pressure wound to the right sacrum, unstageable wound to the scrotum and an unstageable DTI of the right heel that were all identified on 3/25/26 by the wound care doctor. 2. The facility failed to complete a comprehensive skin assessment or initiate timely treatment orders for several significant pressure injuries for CR#1. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (Resident #12) of 5 residents reviewed for care plans. The facility failed to ensure Resident #12's dentures were on her care plan. This failure could place residents at risk of unmet ADL needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 5 residents (Resident #7) reviewed for ADLs. The facility failed to ensure Resident #7 was provided with fingernail care. This failure could place residents at risk of infection and discomfort.

Inspectors wroteBased on observation, interview, and record review the facility staff failed to ensure residents with incontinent bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 3 resident (Resident #13) reviewed for incontinent care. The facility failed to ensure Resident #13 had a securing device in place for her urinary catheter on 05/13/26. This failure could place residents at risk for skin breakdown, pressure ulcers, infections, pain, and/or decline in quality of life/ADLs.

Inspectors wroteBased on observation, interview and record review, the facility failed to permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse for 1 of 6 residents (Resident #6) reviewed for pharmacy services. The facility failed to ensure that Resident #6 was given medication by a licensed/certified staff member on 05/13/26. This failure could place residents at risk of not receiving the therapeutic benefit of the medication and/or worsening health concerns.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure appropriate information was communicated to the receiving health care institution prior to discharge for 1 of 6 residents (Resident #1) reviewed for transfer or discharge. The facility failed to ensure that the discharge destination and continuing care provider could meet the resident's needs prior to the discharge. Resident #1 was discharged on 09/29/25 without ensuring the provider could meet the residents' needs. This failure placed residents at risk of not getting the necessary care and services to meet physical and psychological needs. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 (Resident #2) of 7 residents reviewed for care plans. The facility failed to ensure Resident #2's care plan was updated to reflect the need for feeding assistance according to his primary care provider on 11/19/2025. This failure could place residents at risk for choking and unwanted weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain nutrition, grooming and personal and oral hygiene for 1 of 7 residents (Resident#3) reviewed for ADLs. The facility failed to ensure Resident #3 was provided fingernail care. This failure could place residents at risk for infections and a decreased quality of life. Record review of Resident #3's quarterly MDS assessment, dated 10/10/25, revealed an [AGE] year-old male admitted on [DATE], and readmitted on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide special eating equipment and utensils for residents who needed them and appropriate assistance to ensure that the resident could use the assistive devices when consuming meals for 1 resident (Resident #2) of 6 residents reviewed for food and nutrition services. The facility failed to assess and provide Resident #2 with an assistive device to help prevent food from accidentally being pushed off the plate while eating during meal service to minimize food spillage. This failure could place residents at risk for harm by weight loss, diminished independence, and self-esteem. Record review of Resident #2's quarterly MDS assessment, dated 09/01/25, revealed Resident#2 was a [AGE] year-old male admitted on [DATE] and readmitted on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 7 residents (Resident #6) reviewed for infection control. CNA B failed to wear a gown when she performed incontinent care for Resident#6 who was on EBP on 11/18/25. CNA B failed to change gloves and perform hand hygiene when going from dirty to clean during Resident #6's incontinent care on 11/18/25. This failure could place residents at risk of cross-contamination and infections. Record review of Resident #6's quarterly MDS assessment, dated 11/07/25, reflected Resident #6 was an [AGE] year-old male admitted [DATE]. [...]

Inspectors wroteBased on observation and interview the facility failed to ensure all patient care equipment was in safe operating condition for 1 resident (Resident#2) of 7 residents reviewed for safe operating patient care equipment. The facility failed to ensure Resident #2's bed had a working remote control. This failure could place residents at risk of living in an unsafe and un-homelike environment. Record review of Resident #2's quarterly MDS assessment, dated 09/01/25, revealed Resident#2 was a [AGE] year-old male admitted on [DATE] and readmitted on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident's bedside and toilet and bathing facilities were adequately equipped to allow all residents to call for staff assistance through a communication system which relayed the call directly to a staff member or a centralized staff work area for 2 of 7 residents (Resident#4, and Resident#5) reviewed for residents' call system. The facility failed to provide a working communication system, that was easily at reach, that would allow Resident #4 and Resident#5 the ability to safely call for staff for assistance. This failure could place residents at risk of not having a means of directly contacting caregivers in an emergency or when they needed support for daily living.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident environment remained free of accident hazards, and each resident received adequate supervision to prevent accidents for 1 (CR #1) of 7 residents reviewed for accidents and supervision. The facility failed to ensure CR #1 did not leave the facility unattended on 3/21/25. CR #1 was found by another staff member approximately 1 mile away in a parking lot near the freeway. An immediate jeopardy (IJ) was identified on 10/22/25. The IJ template was provided to the facility on [DATE] at 5:01 p.m. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three of three residents (Resident #1, #2 and #3) reviewed for infection control. CNA B failed to perform hand hygiene after pericare for Resident #2 and before exiting the resident's room. CNA B, CNA H and CNA C failed to follow EBP (enhanced barrier precaution) signs and did not wear gowns during high contact resident care activities for Residents #2 and #3. CNA C failed to sanitize the mechanical lift between use for Resident #3 and Resident #2. CNA A failed to put on clean gloves during pericare for Resident #1. CNA A put on gloves from her pocket and not from the box of gloves in the room. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24-hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials (which included the State Survey Agency and Adult Protective Services where state law provides for jurisdiction in long-term care facilities) in accordance with State Law through established procedures for 1 of 7 residents (CR #1) reviewed for abuse and neglect. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Residents who are incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 4 residents (Resident#1) reviewed for incontinent care. CNA A failed to wash Resident #1 external urethral orifice (the opening at the end of the urethra where urine exits the body) during perineal care (cleansing of the genital and anal areas to maintain hygiene). This failure could place residents at risk of infection and hospitalization.

Inspectors wroteBased on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 1 of 8 resident (Resident #1) reviewed for pharmaceutical services. The facility failed to have an authorized staff administer medication to Resident #1. MA-I instructed CNA- A who was not authorized to apply Lidocaine patches to Resident #1's hips. The facility failed to clarify the physician order for Resident #1's Lidocaine patch as to which hip the patch was to be applied. CNA-A applied one patch to Resident #1's right hip and a second patch to the left thigh. This failure could place residents at risk of not receiving medications as ordered by the physician. [...]

Inspectors wroteBased on interview and record reviewed, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (CR #1) of 5 residents reviewed for quality of care. - The facility failed to ensure treatment and care was provided to CR #1 who was taken to the hospital by their family member on 07/28/25 and found to have transient (brief) alteration of awareness, herpes zoster (shingles) with complication, and acute cystitis without hematuria (bladder infection without the presence of blood). This failure could place residents at risk of not receiving necessary medical care and a decline in health.

Inspectors wroteBased on observation, record reviews, and interviews, the facility failed to ensure a resident's environment remained as free of accidents and hazards as possible for 1 of 6 residents (CR #1) reviewed for accidents and hazards in that: - The facility failed to ensure the environment remained free of accident and hazards when CNA D and CNA W transferred CR #1 from her wheelchair to the bed on 2/2/25, and she sustained a laceration to her R leg requiring 15 sutures and 18 staples. An Immediate Jeopardy (IJ) was identified on 2/26/25. The IJ template was provided to the facility on 2/26/25 at 4:30pm. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living (ADL's) received the necessary services to maintain nutrition, grooming and personal and oral hygiene for 3 of 5 residents (Residents #50, #84 and #82) reviewed for ADL's. The facility failed to ensure Resident #50 and Resident #84 received showers per facility schedule. The facility failed to ensure Resident #82 was provided fingernail care. This failure could place residents at risk for infection, discomfort, and dignity issues.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (Resident #21) of 5 residents reviewed for care plans. The facility failed to ensure Resident #21's fall mat was at the bedside according to her care plan. This failure could place residents at risk of injury.

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 7 residents (Resident #207) reviewed for Infection Control. - LVN B failed to wear a gown when she gave an IV antibiotic to Resident #207, who was on EBP. This failure could place residents at risk of cross-contamination and infections.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 (CR #1) of 4 residents reviewed for respiratory care. The facility failed to ensure CR #1, who was on continuous oxygen, was provided with sufficient oxygen while out of the facility at an MD appointment on [DATE]. CR #1 was transported to the hospital from the MD appointment. An Immediate Jeopardy (IJ) was identified as past noncompliance on [DATE]. The noncompliance began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the investigation began on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 1 (CR #1) of 5 residents reviewed for quality of care. -The facility failed to ensure treatment and care was provided to CR #1 for approximately 4 hours after she had a change in condition with sudden onset of mental status and neurological deficits on 10/02/24 at approximately 12:37 p.m. CR #1 was not transported to the ER until approximately 4:39 p.m. where she passed away on 10/15/24. -The facility failed to monitor CR #1 after having a change in condition on 10/02/24 for approximately 4 hours. An IJ was identified on 01/24/25. The IJ template was provided to the facility on [DATE] at 5:34 p.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, which included measurable objectives and time frames to meet resident's medical, nursing, and mental and psychological needs that were identified in the comprehensive assessment for 3 out of 18 residents (Resident #36, Resident #53, and Resident # 69) reviewed for comprehensive care plans. - The facility failed to ensure Resident #36's special activities were added to the care plan, since she was blind. - The facility failed to ensure Resident #53's exit seeking behavior and wander guard were added to the care plan. - The facility failed to ensure Resident #69's midline and IV antibiotics were added to the care plan. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 5 (Resident rooms 303D, 403D, 306W, 301D, 301W) out of 18 resident rooms reviewed for physical environment. - The facility failed to ensure call lights were properly functioning for resident rooms 303D, 403D, 306W, 301D, 301W. This failure could place residents at risk of falls and/or injuries if they are unable to get staff assistance when needed.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure comprehensive care plans were reviewed and revised by the Interdisciplinary Team after each assessment for 1 (Resident #36) out of 18 residents reviewed for care plan accuracy. - The facility failed to ensure Resident #36's comprehensive care plan had the correct ADL interventions. This failure could place residents at risk for their medical, physical, and psychosocial needs not being met.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services provided by the facility met professional standards of quality for 1 of 18 residents (Residents #7) for professional standards. - The facility failed to follow physician orders and remove a Wander Guard from Resident #7 when it was discontinued 10/29/23. This failure could place residents at risk of unnecessary treatment and from maintaining their highest practicable quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received necessary services to maintain good personal hygiene for 2 (Residents #6 and #61) out of 18 residents reviewed for ADL care. - The facility staff failed to provide scheduled showers to Resident #6, and Resident #61. This failure could place residents who were unable to carry out ADLs independently, at risk of skin breakdown, pain, and infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the residents' choices for 1 of 18 residents (Resident #2) reviewed for quality of care. - The facility failed to ensure nursing performed thorough skin assessments on Resident #2. - The facility failed to ensure nurse aides communicated Resident #2's skin tear to nursing staff for at least 2 weeks. These failures could place residents at risk for skin breakdown, infection, and hospitalizations.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the medication error rate was not five percent (5%) or greater. The facility had a medication error rate of 14.29%, based on 5 errors out of 35 opportunities, which involved 1 of 7 residents (Resident #31), and 1 of 5 staff (LVN F) reviewed for pharmacy services. - The facility failed to ensure LVN F diluted crushed medications in water (Carvedilol 3.125mg, Docusate Sodium 100mg, Midodrine 5mg, and Renal-Vite 0.8mg), and instead poured the crushed medication directly into the G-tube syringe. - The facility failed to ensure LVN F diluted Potassium Chloride liquid 20meq/15ml, with 3oz of water first, and instead poured the liquid straight into the G-tube syringe. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents were free from any significant medication errors for 1 of 18 (Resident #31) residents reviewed for pharmacy services. - The facility failed to dilute Resident #31's G-tube medication (Carvedilol 3.125mg), which lowers BP, before administering it into the syringe. This failure could place the resident at risk of not receiving the intended dosage, causing high BP, a clogged G-tube, and potential hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 8 residents reviewed (Resident #339) for infection control, in that: The facility failed to ensure LVN F donned (put on) an isolation gown when she entered Resident #339's room who was on contact isolation for MRSA (Methicillin Resistant Staphylococcus Aureus Infection). This failure could place residents at risk of contracting a communicable disease.