Double Tree Post Acute Care Center

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure industry standards for food safety were met for a resident population of 102, when: Kitchen walls had chipped paint and damaged dry walls, food shelves were rusty, vents over food production area were rusty, floor tiles were chipped, and linoleum tiles had dark discoloration and rust stains making it difficult to determine if clean and sanitary;Spices were labeled using inconsistent use by dating system and one spice had expired;Plastic containers and lids were stacked and stored while wet in ready-to-use area; A metal colander was observed with dried food inside the openings and along the base, a plastic scoop had food residue inside its bowl, and a knife case had dust and crumbs all along the top near insertion sites. All were found in the clean ready-to-use area; [...]

Inspectors wroteBased on observation, interview and record review, the pureed and alternate foods made for lunch on 1/21/26 were not made by methods that conserved nutritive value, flavor and appearance when recipes were not utilized. This failure had the potential to lead to poor intake, weight loss and malnutrition for the 6 residents eating the chicken entree and 10 residents (Residents 2, 14, 16, 24, 42, 52, 63, 71, 90 & 95) receiving the pureed pot roast and pureed peas.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 46) for unnecessary medications, received safe and adequate monitoring of a psychotropic medication (any drug that affects behavior, mood, thoughts or perception), when Resident 46's Lithium (a naturally occurring salt used as a powerful mood stabilizer medication) level had not been ordered or drawn since 12/26/24. This failure had the potential to put Resident 46 at risk for ineffective low Lithium levels and/or levels that were too high which could lead to toxicity (a potentially fatal condition that occurs when too much Lithium builds up in the blood).

Inspectors wroteBased on the interview and record review, the facility failed to report an allegation of theft within 24 hours to CDPH (California Department of Public Health) for one of 28 sampled residents (Resident 102). This failure delayed the theft allegation investigation by the department and had the potential to compromise Resident 102's safety and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident 74) in a census of 102, received his nasal spray medication properly when Licensed Nurse (LN) did not follow the medication administration instructions. This failure had the potential risk for Resident 74's not getting the full benefits of the nasal spray medication and could worsen the allergy symptoms.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services in accordance with professional standards of practice for one of 28 sampled residents (Resident 113), when:1. The facility did not obtain Resident 113's hemoglobin A1c (HbA1c-a test that indicates the average level of blood sugar [BS] control, a high or low number is a sign of poor blood sugar control) as ordered by the physician;2. The facility did not provide the required diabetic education for Resident 113; and3. The facility did not provide diabetic training, for licensed staff, year 2025 to current date. These failures had the potential to negatively compromise the necessary quality of care and treatment for Resident 113. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a safe environment for one of 28 sampled residents (Resident 83) when resident 83's call light was not in reach. This failure had the potential to result in injury of Resident 83.

Inspectors wroteBased on observation, interview, and record review, the facility failed to address Resident 46's weight loss of 22 pounds over 6 months. This had the potential of leading to Resident 46's malnutrition, muscle loss and functional decline.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate care and services were provided for one of twenty-eight sampled residents (Resident 8), when Resident 8's swallow evaluation (test performed to determine if food or liquid is passing safely to the stomach without entering the lungs) was not rescheduled and completed. This failure had the potential to result in delayed restoration of eating and placed Resident 8 at risk for aspiration (choking).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 35 sampled residents (Resident 119) received his diabetic medications with meals as ordered. This failure could potentially result to Resident 119's blood sugar level to drop in dangerous levels and suffer stomach upset.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications of a discharged resident were removed from the nurse's medication cart and mixed with other residents' active medication supplies. This failure had the potential to result in medication errors when the medications were accidentally given by mistake to other residents. During a facility task observation, two medication carts were inspected on [DATE] at 1:21 p.m. Cart #3 was inspected together with Licensed Nurse 3 (LN 3). Inside med cart #3, the lower medication cart drawer contained oral, liquid, and topical medications of active residents. The same lower drawer also contained one box of lidocaine patch which belonged to a resident who was discharged on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review, the facility Registered Dietitian lacked the skill set to assess a non-English speaking resident (Resident 11) when language interpreter services were not utilized though the resident appeared to have lost 22 pounds during her 3 months at the facility. This failure had the potential of leading to further weight and muscle loss as well as malnutrition for Resident 11.

Inspectors wroteBased on observation, interview and record review, the facility failed to protect the resident's right to be free from abuse for one of seven sampled residents (Resident 1) when Resident 2 hit Resident 1 in the head. This failure resulted in Resident 1 having pain and dizziness and had the potential for Resident 1 to experience physical and/or psychosocial harm.

Inspectors wroteBased on observation, interview and record review, the facility failed to protect the resident's right to be free from physical abuse for one (Resident 1) out of a census of 108 when Resident 1 was pushed by a visitor during an altercation. This failure resulted in Resident 1 not free from abuse by a visitor.

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of abuse was reported timely within 2 hours for one of four sampled residents (Resident 1), when an allegation of abuse was reported to the department the following day. This failure reduced the potential to ensure resident safety.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by a resident for one of three sampled residents (Resident 2) when facility staff witnessed Resident 1 hit Resident 2. This failure resulted in Resident 2 not being free from abuse and had the potential for Resident 2 to be injured.

Inspectors wroteBased on observation, interview and record review, the facility failed to properly manage a resident's Type 2 Diabetes Mellitus (DM2-a disease that results in too much glucose, also called blood sugar in the blood) for one of 28 sampled residents (Resident 31) when the Licensed Nurses (LN) did not follow Physician Orders and the standards of care for diabetes. These failures resulted in Resident 31 having dangerously high levels of glucose throughout the day and suffering from unwanted symptoms of hyperglycemia (high sugar level) which could have led to a diabetic coma, a life-threatening medical emergency requiring immediate medical care or death if left untreated.

Inspectors wroteBased on observation, interview, and record review, the facility failed to verify, document, seal, and replace an opened E-Kit (emergency kit, a limited supply of medications in the facility to use during an emergency or after-hours) for a census of 116 residents. This failure had the potential to have expired pharmaceutical products, contribute to decreased availability of medications in an emergency or increase the risk of drug diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate did not exceed 5% for two of 28 sampled residents (Resident 31 and 103). 1. For Resident 31, Licensed Nurse (LN) 1 did not administer Resident's Humulin Insulin medication used to lower blood sugar level, in accordance with the Physician Order. 2. For Resident 31, LN 1 did not administer Resident's glipizide, a medication given 30 minutes before breakfast to lower blood sugar level, 5 mg (milligram, unit of measure) in accordance with the Physician Order. 3. For Resident 103, LN 1 administered lactobacillus, a probiotic to aid in digestion, without clarifying the Physician Order. These failures exposed the residents to possible adverse reactions and health complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 28 sampled residents, Resident 31 was free from significant medication errors when: 1. For Resident 31, Licensed Nurse (LN) 1 did not administer Resident's Humulin R Insulin, medication used to lower blood sugar level, in accordance with the Physician Order. 2. For Resident 31, LN 1 did not administer Resident's glipizide, medication to be given 30 minutes before breakfast used to lower blood sugar level, 5 mg (milligram, unit of measure), according to the physician order. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored correctly, when: 1. Three unopened bottles of latanoprost ophthalmic solution, an eye drop medication used to treat an eye condition, 0.005% (percentage, unit of measure), 2.5 ml (milliliter, unit of measure) were not kept in the medication refrigerator per manufacturer's instructions before opening. 2. An opened glucose test strip bottle was found in the medication cart #1 did not have an open date to determine its expiration date. 3. An opened bottle of insulin lispro, medication used to treat high blood sugar levels, 100 unit/ml (unit per milliliter, unit of measure), was found in the medication cart #1 without an open date to determine its expiration date. 4. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the walk-in freezer in safe operating condition in a census of 115 residents who received facility prepared foods, when the walk-in freezer had ice buildup on the walls, ceiling, and boxes of food. This failure had the potential to cause the freezer to not operate efficiently, which would result in possible contamination of food leading to food borne illnesses and decreased food quality.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 25 sampled residents' (Resident 100 and Resident 72) planned meal tray tickets (guidance to staff on what to serve for a meal to a resident) were accurate and followed. This failure had the potential to negatively impact Resident 100's and Resident 72's nutritional status and potentially result in unplanned weight lost.

Inspectors wroteBased on interview and record review, the facility failed to ensure four of seven sampled residents (Resident 1, Resident 2, Resident 3 and Resident 4) were free from abuse when: 1. Resident 1 and Resident 2 had an altercation resulting in Resident 2 sustaining a skin tear; and 2. Resident 3 and Resident 4 had an altercation resulting in Resident 3 sustaining a skin tear. These failures had the potential to result in serious physical injury to the residents.

Inspectors wroteBased on observation, interview and review of facility documents, the facility failed to ensure infection control guidelines were followed for 1 of three residents (Resident 3) in a census of 115, when Resident 3's privacy curtain had multiple soiled areas. These failures had the potential to increase the risk for the development and transmission of communicable disease and infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an effective pest control program was provided for a census of 109, when roaches, ants and flies were found in multiple locations throughout the building. This failure resulted in the presence of pests inside the facility and had the potential to result in the transmission and spread of infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a safe, clean, comfortable and homelike environment was provided for six of 35 sampled residents (Resident 10, Resident 55, Resident 64, Resident 511, Resident 512, Resident 517), when: 1. Broken window blinds were found in Resident 10's room; 2. Flies were observed in Resident 55's room; 3. Walls in Resident 64's room had multiple holes and cracks; 4. A used bandage covered with ants was found in Resident 511's room; 5. Two used urinals in the closet drawers, broken window blinds, and over-bed light cord consisted of two garbage bags tied together were found in Resident 512's room; and 6. Several cockroaches were found in the light fixture and on the floor in Resident 517's room. These failures had the potential to result in the residents not maintaining their mental, physical and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement comprehensive care plans for three out of 35 sampled residents (Resident 72, Resident 76, and Resident 78), when no person-centered communication care plans with interventions were in place to address the residents' needs. This failure had the potential to result in the residents not attaining their highest practicable physical, mental and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pharmacy services were maintained for three residents (Resident 89, Resident 86, and Resident 74) of 35 sampled residents when: 1. Antidiabetic-medication (medicine to control blood sugar) was not ordered and delivered on time resulting in a missed dose for Resident 89, and 2. Controlled medication (medications with a likelihood for physical and mental dependence) drug records had discrepancies for Resident 86 and Resident 74. These failures had the potential to result in poor control of Resident 89's diabetes (a chronic condition that affects the way the body processes blood sugar) and controlled medication diversion (the illegal distribution of prescription drugs not intended by the prescriber).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate did not exceed 5% for two residents (Resident 57 and Resident 517) of 35 sampled residents when: 1. Resident 57 was administered sodium bicarbonate (medication used to treat heartburn or sour stomach) 325 mg (milligram: a unit of measure) instead of 650 mg as prescribed; and, 2. Resident 517 was administered a crushed potassium chloride (medication to prevent or treat low potassium levels) extended release (ER) tablet and was not administered zinc sulfate (medication to prevent or treat low zinc levels) 220 mg and Vitamin B+C Complex with Folate (medication to prevent or treat low vitamins) as prescribed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored correctly for a census of 109 residents, when: 1. Pharmaceutical products were not kept within the required temperature range in the medication refrigerator; 2. Products were opened without open dates labeled in medication cart; 3. Expired medications were available for use in medication cart; 4. Medications and syringes were found behind a drawer of the medication cart; 5. Loose pills were found in the medication carts; 6. The treatment cart had prescription products inside without a lock mechanism; 7. Prescription products were without pharmacy labels in the treatment cart; and, 8. A controlled medication cabinet was not permanently affixed. These failures had the potential for medication misuse, drug diversion and medication ineffectiveness.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the nutritive value of meals was not compromised, when: 1. Pureed food was not prepared according to recipe; and 2. Vegetarian meal plan was not developed and/or followed. These failures had the potential to result in malnutrition for the 16 residents eating pureed meals, and the one resident who followed a vegetarian diet.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an acceptable amount of time in between dinner and breakfast was provided to 108 residents, when there was more than excess of 14 hours between the dinner meal and breakfast the following day. This failure had the potential to result in abnormal blood sugar levels and/or discomfort to residents who experienced excessive hunger.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety for a total of 109 residents who received facility prepared foods, when: 1. A box of chocolate chips was not labeled or dated; 2. Open boxes of graham crackers crumbs and chocolate chips were found with inner bags not closed; 3. A container of tuna salad in the refrigerator was found to be out of safe temperature range; and 4. A refrigerator used for storing resident food was out of safe temperature range. These failures had the potential to result in food-borne illnesses.

Inspectors wroteBased on interview and record review the facility failed to ensure the safe and sanitary storage, handling, and consumption of food was provided for a census of 109, when staff did not understand and did not follow the facility's policy and procedures for outside food brought in for residents. This failure had the potential to result in the residents' limited food options and enjoyment of outside meals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the infection prevention and control program guidelines and practices were maintained for a census of 109, when: 1. Expired hand sanitizers were used by staff and residents; 2. Three urinals with no label and date were found in Resident 87's room; 3. Three wheelchair armrests had sharp pointy edges sticking through the padding for Resident 3, Resident 20, and Resident 64; and 4. Intravenous (IV, plastic tube within a vein for medication administration) tubing was not labeled for Resident 406. These failures had the potential to result in the spread of infection to a vulnerable population.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain resident care equipment in safe operating condition for 108 residents who received food from the kitchen, when an ice build-up was found in walk-in freezer. This failure had the potential to result in the freezer not maintaining the appropriate temperatures and decreasing food quality and safety leading to food-borne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, sanitary, functional and comfortable environment for a census of 109, when: 1. Flies were found in Resident 55's room; 2. Resident 78 had a nightstand with a broken drawer; 3. Resident 10's meal tray had a fly in his food while having lunch in the dining room; 4. A cockroach was found in the dining room; 5. Resident 3, Resident 20, and Resident 64 had torn wheelchair arm rests; and 6. Several cockroaches were found in light fixture and on the floor in Resident 517's room. These failures had the potential to result in the residents not attaining their highest practicable physical, mental and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dignity was provided for one of 34 sampled residents (Resident 78), when Resident 78 was found alone in the bathroom wearing a dirty shirt, had no communication binder at bedside, and the room was disorganized with a piece of furniture in disrepair. This failure had the potential to negatively impact Resident 78's quality of life and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to respect the rights of one resident (Resident 517) out of 35 sampled residents, when Resident 517 refused to take a laxative (a medication that helps have bowel movements) and the Licensed Nurse (LN) administered the laxative anyway. This failure contributed to the resident's diarrhea and had the potential to have led to dehydration.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, an assessment tool) accurately reflected the resident's current condition for one of 35 sampled residents (Resident 72), when the hearing status was coded incorrectly. This failure resulted in Resident 72's MDS data submitted to CMS (Centers for Medicare-Medicaid Services) inaccurately and had the potential for Resident 72 to not receive appropriate treatment and care to attain her highest practicable quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to review and revise the comprehensive care plan for one of 35 sampled residents (Resident 76), when the care plan did not reflect the resident's current health status and needs. This failure had the potential to result in Resident 76 receiving outdated care and placing the resident at risk for not meeting her highest practicable well-being.

Inspectors wroteBased on interview and record review the facility failed to ensure care and services were provided according to professional standards for two of 35 sampled residents (Resident 516 and Resident 519) receiving dialysis (removal of extra fluid and waste products when the kidneys are not able to) when: 1. Monitoring was not ordered for Resident 516's dialysis access site (entrance way into the bloodstream that lies beneath the surface of the skin and monitor for bleeding); and 2. Physician's orders for daily weights were not followed for Resident 519. These failures had the potential to result in undetected complications such as bleeding in Resident 516 and increased fluid retention in Resident 519.

Inspectors wroteBased on interview and record review, the facility failed to act on a previously reported medication irregularity (use of medication that is inconsistent with accepted pharmaceutical services standards of practice) identified during a Medication Regimen Review (MRR) in June and July of 2023 for one resident (Resident 52) of 35 sampled residents. This failure resulted in Resident 52 receiving an antipsychotic medication (a drug prescribed to affect the mind, emotions or behavior) without an adequate indication (valid reason to take a medication).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two residents (Resident 52 and Resident 55) of 35 sampled residents were free from unnecessary psychotropic medication when: 1. Resident 52 was prescribed antipsychotic medication (medication to treat psychiatric illness) without documented behavioral symptoms that presented a danger to himself or others; and 2. Resident 55 was prescribed antipsychotic medication for an inadequate indication (valid reason to take a medication). These failures increased the potential for Resident 52 and Resident 55 to experience side effects from these medications such as frequent falls, sedation, and abnormal involuntary movements.