Dept of State Hospitals - Metropolitan SNF

Inspectors wroteBased on interviews and record review, the facility failed to ensure that an alleged violation of neglect was reported within 24 hours to the administrator and that the SOC 341 ( Report of Suspected Dependent Adult/Elder Abuse - a mandated California Department of Social Services form used by professionals to report suspected abuse and neglect) was initiated timely when an alleged staff was observed asleep while performing Line of Sight (LOS-a safety intervention requiring continuous direct visual) observation to Resident 1. This failure had the potential to delay the initiation of a timely investigation and implementation of interventions to ensure Resident 1's safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop written policies and procedures (P&P) that clearly defined all forms of abuse to include resident-to-resident abuse. This failure resulted in the facility's inability to recognize and identify three of three sampled incidents involving resident-to-resident physical and alleged sexual assault as abuse when1. Resident 2 punched Resident 1 in the face while Resident 1 slept and Resident 2 alleged sexual assault and stated he [Resident 1] tried to have sex with me.2. Resident 3 kicked Resident 4 in the buttocks and Resident 4 punched Resident 3 in the face three times.3. Resident 5 allegedly punched Resident 6 in the chin after a verbal altercation. Consequently, the facility failed to prevent abuse, protect residents from abuse, conduct abuse investigations, report timely, and accurately train staff. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the resident's right to be free from physical abuse (any intentional act causing injury or trauma to another person through bodily contact) by another resident for one of six sampled residents (Resident 1) when Resident 2 punched Resident 1, in the face while Resident 1 slept. The facility failed to implement adequate supervision, environmental interventions, and behavioral interventions for Resident 2, who the facility had previously identified as a moderate risk for violence against others to prevent foreseeable harm. These failures resulted in Resident 1, a medically fragile resident, sustaining a laceration to his eyebrow requiring medical attention and experiencing a loss of safety and subsequently placed all other residents at risk for potential abuse. The facility census was 53. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure all staff received adequate training on the recognition, prevention, and reporting of all forms of abuse, including resident-to-resident abuse in accordance with Federal regulations. This failure resulted in staff's inability to recognize incidents involving resident-to-resident physical and alleged sexual assault as abuse for two of six sampled residents (Resident 1 and Resident 2). Cross reference F600, F607, F609 and F610.

Inspectors wroteBased on interview and record review, the facility failed to identify all forms of abuse to include resident-to-resident abuse for three of three sampled allegations, when:1. Resident 2 punched Resident 1 in the face, alleging that Resident 1 attempted to engage in unwanted sexual activity with Resident 2.2. Resident 3 kicked Resident 4 in the buttocks and in retaliation Resident 4 punched Resident 3 in the face three times.3. Resident 6 reported an allegation that Resident 5 punched him in the chin. These failures resulted in the required authorities, patients' rights advocate (PRA-designated individual that helps patients navigate the healthcare system, ensuring their legal, civil and human rights are upheld) and the state survey agency (CDPH- California Department of Public Health) not being notified immediately, but not later than 2 hours after the allegation was made. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all alleged violations that involved abuse, including alleged sexual assault and physical abuse, were thoroughly investigated for 2 of 6 sampled residents (Resident 1 and Resident 2) when:Resident 2 alleged sexual assault and stated he [Resident 1] tried to have sex with me. Resident 1 was physically assaulted by Resident 2 while he was sleeping. Consequently, the facility failed to report the results of all investigations to the State Survey Agency (SA) within 5 working days of the incident. These failures resulted in the investigations not being conducted and placed Resident 1 and Resident 2 at risk for further harm. Cross reference to F600, F607 and F609.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide ongoing assessment, monitoring and implementation of interventions for one of 21 sampled residents (Resident 10) when on 10/23/2025, Resident 10 was diagnosed with a blood clot in his arteriovenous fistula (AV fistula- surgical connection of an artery and a vein that allows for blood to flow directly to provide a long-term access point for filtering blood in patients with kidney disease) and the physician had an order to check the AV fistula for bruit and thrill (bruit is a swooshing sound heard over a blood vessel, while a thrill is the vibrating or buzzing sensation felt over the same vessel, both indicate a strong blood flow of an AV fistula), on the left upper arm every shift, since 11/24/2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their policy to ensure the provision of pressure-injury (damage to skin from pressure) prevention, monitoring, and treatment were consistent with professional standards of practice for two of 21 sampled residents (Resident 30 and Resident 4). 1. Resident 30's buttocks were previously identified as areas of impaired skin integrity and were not monitored for two months. In addition, Resident 30's Low Air Loss mattress (LAL-pressure relieving air mattress) was not set to the accurate weight in accordance with the manufacturer's instructions. 2. Resident 4's ischial tuberosity (sit bone) was previously identified as an area of impaired skin integrity and was not monitored for three weeks. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food safety and sanitation measures were maintained in the kitchen according to standards of practice and facility policy when:1. Two cutting boards used for food preparation were found to have discolorations and deep gouges on the surface.2. Five resident food trays were dirty with built-up food debris and found stacked in the clean tray area.3. One open box of previously frozen french toast was found uncovered and labeled with a date of 3/25/25. These failures had the potential to place residents at risk for developing foodborne illness (any illness resulting from eating contaminated/spoiled foods) by exposing residents to contaminated food and unsanitary practices.

Inspectors wroteBased on interview and record review, the facility failed to update its Facility Assessment (document that determines the necessary resources to care for residents competently during day-to-day operations and emergencies) annually. In addition the facility failed to include the specific competencies (measurable pattern of knowledge, skills and abilities to perform occupational functions successfully) of the licensed nursing staff and how often the competency evaluations needed to be done to properly care for the residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure their Quality Assurance and Performance Improvement (QAPI- a program that enables a facility to evaluate and improve the quality of Resident care and services through data collection, staff input, and other information), did not implement their plan to identify areas for improvement for residents at risk for developing pressure ulcers (localized damage to the skin and/or underlying tissue usually over a bony prominence). This failure resulted in an ineffective QAPI program that did not identify systemic problems related to the monitoring of pressure ulcers. Cross Reference F686.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection prevention and control practices that protect residents from the spread of communicative diseases and infections when:1. Unit 404's clean linen room had multiple pieces of laundry piled on a chair, in a corner on the floor, and on the floor in front of the storage shelving; there was also uncovered clean laundry storage and an opened water bottle on the floor mixed in with clean laundry.2. Resident 4's foley catheter (medical device- tube that drains urine from the bladder into a bag) collection bag was not below the waistline.3. Licensed Psychiatric Technician (LPT 1) did not wear Personal Protective Equipment (PPE, specialized clothing or equipment used to reduce exposure to hazards or infections), while performing a glucose (blood sugar) monitoring test on Resident 10. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure Licensed nurses were competent (having the necessary ability, knowledge, or skill to do something successfully), in assessing and monitoring dialysis residents when two licensed nurses, Registered Nurse Shift Lead [RNSL 2], and Registered Nurse Unit Supervisor [RNUS]), were unable to properly demonstrate how to assess and monitor for bruits and thrills (bruit is a swooshing sound heard over a blood vessel, while a thrill is the vibrating or buzzing sensation felt over the same vessel, both indicating a strong blood flow of an AV fistula- surgical connection of an artery and a vein that allows for blood to flow directly to provide a long-term access point for filtering blood in residents with kidney disease), for one of 21 sampled residents (Resident 10). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure four of five outside dumpsters were covered. This failure had the potential to attract pests and/or rodents that carried diseases and could result in food borne illness (a sickness caused by consuming food, or drinks contaminated with harmful substances) in a medically fragile population of 60 residents.

Inspectors wroteBased on interview and record review, the facility failed to maintain an effective abuse and neglect training program for 13 of 116 skilled nursing employees (Licensed Psychiatric Technician [LPT] 1, LPT 2, LPT 3, LPT 4, LPT 5, LPT 6, LPT 7, LPT 8, LPT 9, Registered Nurse [RN] 4, RN 5, RN 6 and RN 7), when employee abuse and neglect training was not completed annually. This failure had the potential for abuse and neglect to go unnoticed and/or not reported by the staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor a resident's expressed desire for privacy and dignity for one of 21 sampled residents (Resident 10) when Licensed Psychiatric Technician (LPT 2) denied Resident 10 privacy during medication administration. This failure resulted in Resident 10 being exposed in view of other residents.

Inspectors wroteBased on interview and record review, the facility failed to assess and submit accurate data for two of 21 sampled residents (Resident 1 and 21) when the Minimum Data Set (MDS- federally required assessment tool used to guide resident care) did not reflect Resident 1 and Resident 21's current status. This failure resulted in the transmission of inaccurate data to the Centers for Medicare and Medicaid Services (CMS).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services provided met professional standards of practice when:1. Three of three licensed nurses (Licensed Psychiatric Technician [LPT] 10, LPT 11, LPT 12) inaccurately completed skin assessments for Resident 30. This failure had the potential to result in delayed wound healing and unidentified new wounds.2. Licensed Vocational Nurse (LVN 1) administered Trazadone (a prescription antidepressant medication) to Resident 29 by mouth, instead of crushed via G-tube (surgically placed tube into the stomach for feeding, medication, or drainage) as ordered by the physician. This failure had the potential to result in Resident 29 aspirating (accidentally inhaling food, liquids, particulates into the lungs).

Inspectors wroteBased on interview and record review, the facility failed to ensure the environment remained free from accidents for one of 21 sampled residents (Resident 51), when the net zipper of Resident 51's enclosure bed (specialized bed with mesh walls that zip closed around a resident to prevent falls) malfunctioned and Resident 51 got up from bed and fell on the floor. This failure had the potential for serious injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care consistent with professional standards of practice for two of 21 sampled residents (Resident 9 and Resident 10) when:1. Resident 9's oxygen order did not specify amount or frequency of oxygen to be administered.2. Resident 10's CPAP (Continuous Positive Airway Pressure- machine that delivers pressurized air through a mask to keep airways open during sleep, prevents breathing pauses and improves oxygen levels), machine was not cleaned or maintained for over six months.3. Resident 10's oxygen concentrator humidifier (small, water-filled bottle attached to an oxygen machine which adds moisture to oxygen therapy for comfort), was not changed in 4 days. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three of 16 sampled residents' (Resident 15, Resident 32 and Resident 49) medical records were complete when:1. For Resident 32, the staff did not document on the Repositioning Schedule.2. For Resident 15, the staff did not document on the Repositioning Schedule. 3. The Medication and Treatment Record (MTAR) for Resident 49 had missing entries. These failures had the potential to negatively affect the plan of care related to the specific care being provided and monitored.

Inspectors wroteBased on interview and record review, the facility failed to follow policy and procedure in reporting allegations of abuse for one of three sampled residents (Resident 2), when Resident 2 reported an allegation of physical and sexual abuse to the Psychologist and this was not reported immediately after the allegation was made to the required designee's and authorities, including the state survey agency (CDPH, California Department of Public Health). This failure resulted in the delay of the investigation process and the potential in leaving Resident 2 and other residents unprotected from abuse.

Inspectors wroteBased on interview and record review, the facility failed to complete an annual performance evaluation on Psychiatric Technician (PT 1) for eight years. This failure had the potential to prevent PT 1 and other employees from acquiring the necessary skills to meet their job expectations.

Inspectors wroteBased on interviews and record review, the facility failed to ensure medical records were complete and accurately documented for one of three sampled residents (Resident 1), when Resident 1's leaking Gastrostomy-tube (G-Tube - feeding tube the provides nutrition to people who cannot eat or swallow safely) assessment was not documented. This failure had the potential to negatively affect Resident 1's care.

Inspectors wroteBased on interview and facility record review, the facility failed to have a written Quality Assurance Performance Improvement (QAPI - a program that enables the facility to evaluate and improve the quality of Resident care and services through data collection, staff input, and other information) plan in place that identified areas of improvement for the Skilled Nursing units. This failure resulted in an ineffective QAPI program that did not identify systemic problems in the Skilled Nursing units related to infection prevention and enhanced barrier precautions (EBP- use of gown and gloves during high contact resident care activities, designed to reduce spread of infections) (cross reference F 880 and F 945).

Inspectors wroteBased on interview and record review, the facility failed to ensure the Quality Assessment and Assurance (QAA) committee had the required members in attendance. This failure had the potential for quality care improvement activities related to Infection Control to not be evaluated and revised as needed and the potential to negatively impact the quality of resident care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to help prevent the transmission of communicable diseases and infections for six of 22 sampled residents (Residents 7, 36, 1, 35, 11 and 54) when: 1. The trash and linen carts were placed outside of Resident 7's isolation room. 2. Psychiatric Technician (PT) 2 accepted a pitcher handed by Resident 7, who was on isolation precautions, with bare hands. 3. Registered Nurse (RN) 7 performed wound care to Resident 36 wearing gloves as the only personal protective equipment (PPE) used. 4. PT 1 performed wound care to Resident 1 wearing gloves as the only PPE used. 5. Psychiatric Technician Assistant (PTA) 2 and PTA 3 changed Resident 35's linen and provided personal hygiene without wearing a gown. 6. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective infection control training program for 94 of 94 staff when the facility did not develop a written policy and training for staff regarding Enhance Barrier Precautions (EBP- use of gown and gloves during high contact resident care activities, designed to reduce spread of infections). (cross reference to F880) This failure had the potential to negatively affect the facility's ability to maintain a safe environment to prevent the spread of infectious diseases among the 54 residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were treated with dignity and respect for two of 12 sampled residents (Residents 13 and 357) when: 1. Registered Nurse (RN) 3 was standing while feeding Resident 13 in bed. 2. Registered Nurse (RN) 1 was standing while feeding Resident 357 in the dining room. These failures resulted in Resident 13 and Resident 357 not being provided a respectful and dignified dining experience.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 22 sampled residents (Resident 357 and Resident 26) had their call lights within reach. This failure had the potential to result in Resident 357 and Resident 26 not having their needs met.

Inspectors wroteBased on observations, interview, and record review, the facility failed to provide tube feeding (liquid nutrition delivered using a feeding pump directly into the stomach) per the doctor's order for one of two sampled residents (Resident 26). This failure had the potential to result in weight loss and complications of tube feedings for Resident 26.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food service safety and sanitation requirements were met when: 1. Food trays were observed unclean, chipped and with brownish, yellowish stains. 2. Expired foods were found in dry warehouse, freezer and food storage area. 3. One dented can was found in dry warehouse. 4. One heavily marred chopping board was in the food preparation area. These failures had the potential to cause food borne illness among vulnerable residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep food storage areas in the warehouse and main kitchen clean from debris and garbage. This failure had the potential to result in food borne illness in vulnerable residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a qualified facility approved interpreter was provided for one of three sampled residents (Resident 2 ). This failure resulted in Resident 2 being unable to communicate his needs with staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure interventions were implemented to prevent falls for one of three sampled residents (Resident 1). This failure resulted in Resident 1 experiencing a fall which resulted in a scalp contusion (bruise).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure interventions were implemented to prevent falls for one of three sampled residents (Resident 1). This failure resulted in Resident 1 experiencing a fracture to the left fifth finger after a fall.

Inspectors wroteBased on observation, interviews and record review, the facility failed to protect the resident's right to be free from physical abuse by a resident for 1 of 3 sampled residents (Resident 1) when Resident 2 assaulted Resident 1. This failure resulted in physical harm to Resident 1 when he sustained multiple facial lacerations, contusions, and a nasal bone fracture.

Inspectors wroteBased on interview and record review, the facility failed to provide care consistent with professional standards of practice, when the Respiratory Care Practitioner (RCP) failed to follow facility policy and procedure (P&P) for tracheostomy (opening through the windpipe to the outside neck to help a person breath) care. The RCP failed to document Resident 1's assessments in his medical record. This failure had the potential for a decrease in Resident 1's quality of care, due to lack of communication between nursing and the RCP.

Inspectors wroteBased on interview and record review, the facility failed to update the nursing care plans (an individualized plan that provides direction for a resident's medical care) for four of 24 sampled residents (Residents 302, 303, 304, and 352). This failure had the potential to affect the provision of care for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. The shift lead key set and treatment cart key in Unit 404 were not found in a drawer accessible by unlicensed staff. 2. The as needed (PRN) and stat (immediate) medication cabinet was not found unlocked. 3. An expired central line tray (a kit to clean and change the dressing of an intravenous, within the vein, line) and an expired IV (intravenous, within the vein) starter kit were not found in the emergency cart in Unit 404. 4. The narcotic (controlled medication) drawer on medication cart 1 was locked during medication administration in Unit 406. These failures had the potential for unauthorized staff to have access to the medication room, for drug diversion, and expired medical supplies to be used for residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food service safety and sanitation requirements were followed when: 1. Two full trays of Cream of rice, 10 cartons of unopened non-fat milk, 26 cartons of unopened non-fat chocolate milk, and seven unopened bags of tortillas were expired. 2. Kitchen utensils (food grinder and chopping board) were found unclean. 3. Two dented cans of pureed turkey with turkey broth were kept in the storage area. 4. One container of breakfast syrup was opened and not labeled. 5. Four Dietary staff had improper use of hairnets. 6. 14 expired chicken based containers were found in the food storage areas. These failures had the potential to cause food borne illness among vulnerable residents.

Inspectors wrote3. During a tour conducted on 11/27/23 at 12:13 PM, in Unit 404, a quarantine safety alert and an airborne precaution signs were posted next to the entrance door of the unit. The airborne precaution sign indicated, Stop. Airborne Precaution. To prevent the spread of infections, Wash hands or use alcohol based hand sanitizer before entering and upon exiting this room. Put on an N-95 Mask/Respirator before entering this room. (Do not use a standard mask) Keep door closed at all times. During a concurrent observation and interview on 11/27/23 at 12:28 PM, with Psychiatric Technician 2 (PT 2), PT 2 was observed next to door of the day hall with a N-95 respirator mask under his chin. PT 2 stated he removed his N-95 respirator mask because he had to talk to another staff member who was inside the day hall. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a sanitary (clean) environment for two of 24 sampled residents (Residents 251and 252) when: 1. For Resident 251, brown dried formula was observed on the bottom of Gastrostomy (GT-- a tube is inserted through the abdominal wall and into the stomach) Intravenous (IV) pole stand base (a slender portable pole with a wheeled base and hooks on top to hang GT formulas) and dirty used gloves were observed on top of Resident 251's wheelchair lap tray. 2. For Resident 252, brown dried formula was observed on the bottom of the GT IV pole stand base. These failures had the potential for an unsafe environment and increase the risk of infectious germs(potential to cause disease) to residents, staff, and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 24 sampled residents (Resident 1 and Resident 357) that their call lights within reach. This failure had the potential to result in Resident 1 and Resident 357 not having their needs met.

Inspectors wroteBased on interview and record review, the facility failed to schedule and conduct monthly resident council minutes meetings (scheduled meetings where residents voice concerns and grievances to the facility) on a regular basis for fifty-two Residents on unit 404 and 406. This failure had the potential to impede the resident's rights to express their concerns, know their rights, and to socialize as a group in a universe of 52 Residents.

Inspectors wrote2. During an observation on 11/27/23 at 1:28 PM in Unit 406 room [ROOM NUMBER], there was dried up brown liquid, condiment packets and debris located under Resident 151's bed. There was also dried up red-orange spots on the floor around the room. During an interview on 11/27/23 at 1:35 PM with Registered Nurse 7 (RN 7), RN 7 stated, Resident 151 throws her food and coffee. RN 7 stated that housekeeping does come and clean the rooms every shift and she was not sure why the floor was so dirty. During an interview on 11/30/23 at 8:00 AM with Custodian 1 (C 1), C 1 stated, Resident rooms should be cleaned on every shift as well as whenever staff notice rooms need cleaning. C 1 stated, Cleaning involves mopping and getting under furniture, this includes moving beds and dressers. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their policy and procedure on the use of physical restraints (any device or equipment that restricts movement that resident cannot easily remove) for one of 24 sampled residents (Resident 401) when staff did not document Resident 401's response to the restraint and the impact of the restratin on his actiities of daily living. This failure had the potential to result in the unnecessary use of the physical restraint that could lead to the decline of the resident's physical functioning and quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 24 sampled residents (Resident 451) received the necessary services to maintain proper personal care when Resident 451 was observed with dirty fingernails. This failure had the potential to result in Resident 451 developing an infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure interventions were implemented to prevent falls for one of 24 sampled residents (Resident 157). This failure resulted in Resident 157 experiencing an unwitnessed fall that resulted in shoulder pain and had the potential for further falls and injuries.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement the physician order for supplemental hydration (the replacement of body fluids lost through sweating, exhaling, and eliminating waste) to one of 24 sampled residents (Resident 401). This failure resulted in Resident 401 receiving less fluids than ordered and had the potential to place the resident at risk for dehydration (harmful reduction in the amount of water or fluids in the body).

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its tracheostomy care policy and procedure and obtain a physician order for oxygen therapy when: 1. Resident 452's tracheostomy (opening at the front of the neck where a tube can be inserted into the airway to help with breathing) tie change was not performed with the two-person technique. 2. Resident 452's oxygen saturation (measure of how much oxygen is in the blood) was not assessed before, during, and after tracheal suctioning (removing secretions from the airway with a sterile catheter). 3. Sterile (free from bacteria or other living germs) gloves were not used on Resident 452's tracheostomy tie change. 4. Resident 452's tracheostomy care was not properly documented. 5. Resident 356 had oxygen therapy without a physician order. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food safety requirements were followed when: 1. There were two uncovered trash cans in the tray line area. 2. There were two deformed empty grape juice containers found underneath a pallet. There were plastic wrap, paper liner, and chipped wood found in the metal container at the stockroom. These failures had the potential to cause food borne illnesses among vulnerable residents.

Inspectors wroteBased on interview and record, the facility failed to ensure the Infection Preventionist (IP, responsible for the infection prevention and control program) completed 10 hours of Infection Prevention and Control (IPC) continuing education (CE) on an annual basis. This failure had the potential for the IP not to be updated with the latest health care associated infections information and the ability to prevent and manage the spread of infection to residents, staff, and visitors in the facility.