Golden Haven Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a person-centered comprehensive care plan to address the resident's medical and physical needs for one of six sampled residents (Resident 6), who had a history of seizure and was non-compliant in using her soft-shell helmet when out of bed, as per physician's order. This deficient practice had the potential to compromise the facility's ability to provide consistent care specific to Resident 6's needs.

Inspectors wroteBased on interview and record review, the facility failed to monitor three of three sample residents (Resident 7, 67, and 82) reviewed for pharmacy services for the adverse side effects (unwanted, uncomfortable, or dangerous reactions caused by medication or medical treatments) in their drug regimen to prevent unnecessary drug use by failing to: 1. Monitor Resident 7 for the adverse side effect of Tramadol HCL (powerful pain-relieving medication for moderate to severe pain) oral tablet 50 milligrams (mg, unit of mass) that the resident received for pain. 2. Monitor Resident 67 and 82's for the adverse side effect of Hydrocodone-Acetaminophen (Norco, powerful pain-reliving medication for moderate to severe pain) that the residents received for pain. 3. [...]

Inspectors wroteBased on observation and interview the facility failed to ensure foods were properly stored and sealed in accordance with the Policy and Procedure titled, Food storage, preparation, distribution and serving food. This deficient practice had the potential to result in food contamination, growth of microorganisms (disease causing organism) that could cause foodborne illness (food poisoning or food illness due to pathogens (harmful organisms that cause illness such as bacteria, viruses, or parasites) and toxins.

Inspectors wroteBased on observation and interview the facility failed to ensure one of five sampled residents' (Resident 30) call light were within reach and easily accessible for use. This deficient practice had the potential for Resident 30 not to be able to call for assistance when needed especially during emergency and not to receive care or receive delayed care.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 11) was provided a written notice of Bed-hold (holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization) policy upon transfer to the General Acute Care Hospital (GACH) on 1/4/2026. This deficient practice resulted in Resident 11 and/or their representatives not being informed of their rights regarding bed reservation during hospitalization, which could lead to confusion and disruption in continuity of care.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan to indicate interventions in the management of dementia (a general term for a decline in thinking, memory, and reasoning skills severe enough to interfere with daily life) for one of three sampled residents (Resident 3). This deficient practice had the potential for Resident 3's not to received or receive delayed care that is individualized care to the resident's needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the necessary care and services to one of three sampled residents (Resident 30), who was unable to carry out activities of daily living (ADLs) by failing to: 1. Ensure that Resident 30 received services to maintain good oral hygiene as indicated in the care plan by Certified Nurse Assistant (CNA) 3 after Resident 30 finished with her meal. 2. Ensure that Resident 30 was assisted to be properly positioned for her meal. Specifically, on 1/14/2026 Resident 30 was observed in high Fowler's position leaning to her right side when CNA 2 set up tray and cued the resident to start eating. [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to ensure one of three sampled residents (Resident 13) received appropriate services ensuring Restorative Nursing Assistant (RNA) demonstrated proper hand placement while providing passive range of motion (PROM). This deficient practice placed Resident 13 at risk for pain, injury, and compromised joint integrity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care in accordance with professional standards of practice and the facility's policy and procedures for one of three sampled residents (Resident 7) by failing to ensure: 1. Resident 7 was evaluated for the refusal to use Bilevel Positive Airway Pressure (BiPAP, a noninvasive mask-based device used to help residents breathe easier by pushing air into the lungs) machine and implement interventions to ensure the resident received adequate oxygenation. 2. Resident 7 had a physician order was received before the administration of oxygen delivered via nasal cannula (a tubing that connects to the oxygen concentrator machine used to deliver oxygen into the nares) when the resident refused to use the BiPAP. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper use of bed rails (are adjustable metal or rigid plastic bars that attach to the bed) for two of five sampled residents (Resident 4 and 6) by failing to: 1. Attempt to use nonrestrictive measures and other appropriate alternatives prior to installing bed rails. 2. Complete the resident assessment for Resident 6's risk for entrapment (an event in which a resident is caught, trapped, or entangled in the space in or above the bed rail). 3. Implement intervention to monitor the residents for the use of bed rails. These deficient practices had the potential to result in Resident 4 and 6 to be at risk for accident and entrapment that could lead to injuries.

Inspectors wroteBased on interview and record review the licensed nursing staff and physician failed to act upon the pharmacist's recommendations documented in the Medication Regimen Review (MRR, a comprehensive evaluation of a resident's medication regimen intended to promote positive outcomes and minimize adverse effects) to assess the resident's pain condition and add respiratory monitoring to the Physician's Order for the use Morphine Sulfate (Morphine, a potent opioid analgesic, used to treat severe pain) for one of two sampled residents (Resident 5). This deficient practice had the potential for delayed identification of clinical changes, ineffective medication administration, and adverse effects that could lead to acute medical events requiring emergency care or hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to obtain laboratory test as ordered by the physician for one of three sampled residents (Resident 67) who was ordered by Physician (Attending Physician) 1 to obtain urinalysis (urine test to determine presence of infection or other kidney disorder) urine culture (a urine test to identify if bacteria was growing in the urine) after Resident 67 complained of dysuria (painful, burning, or discomfort when urinating) on 1/7/2026. The urinalysis and urine culture test were obtained eight (8) days since the physician ordered the laboratory test after the facility was informed that there was no laboratory test obtained for Resident 67. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to develop a resident centered care plan for one of three sampled residents (Resident 1) after the facility identified a safety concern in which Resident 1's Responsible Party (RP) 1 was observed utilizing the Hoyer lift (a mechanical device used to lift and/or transfer a person) without calling staff for assistance to transfer Resident 1 from the bed to the chair. This deficient practice had the potential for Resident 1's specific care needs and treatment to not be addressed and had the potential for Resident 1 to sustain falls due to unsafe transfers in and out of bed. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one out of seven sampled residents ( Resident 7) was provided a funtioning call light. This deficient practice had the potential to result in a delay in care and untimely response for Resident 7.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three residents reviewed (Resident 1), who was receiving Quetiapine (a medication used to treat bipolar disorder [a mental disorder that results in severe sadness and manic or extreme joy or elated behavior) was monitored for the specific behavior of paranoid delusions (false beliefs that someone is being threatened or mistreated) as indicated for use of the medication. This deficient practice placed Resident 1 at risk unnecessary use of medication and for mismanagement of her mental disorder and expose her to potential side effects associated with taking Quetiapine, such as drowsiness that could lead to accidents and falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary respiratory care and implement interventions in accordance with the resident's needs, care plan, facility policy and professional standards of practice and the physician's order for one of three sampled residents (Resident 77) who had a diagnoses of chronic obstructive pulmonary disease exacerbation (COPD, sudden severe symptoms of a lung disease characterized by poor airflow to the lungs that results in shortness of breath (SOB), difficulty breathing and respiratory distress (a condition that occurs when the body needs more oxygen, resulting in difficulty breathing, rapid breathing, and low blood oxygen levels) and a history of pneumonia (a severe respiratory infection that results in shortness of breath and difficulty breathing) by failing to: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of three sampled residents (Resident 19, 1, and 20) had that their medical records updated to show documentations that: 1. Resident 19, Resident 20, or their Responsible Party (RP) were offered and explained on how to execute an Advance Directive (a written statement of a person ' s wishes regarding medical treatment made to ensure those wishes were carried out should the resident be unable to communicate them to the doctor). 2. Resident 1 and 20 ' s had a Physician Order Life Treatment (POLST, a portable medical order form that records the resident ' s treatment wishes so that emergency personnel know what treatments the resident wants in the event of a medical emergency) had a physician ' s signature. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow and implement the facility ' s Policies and Procedures (P&P) titled, Change of Condition Notification, revised [DATE], for one of three sampled residents (Resident 77) with diagnoses of chronic obstructive pulmonary disease exacerbation (COPD, worsened and severe symptoms of a lung disease characterized by poor airflow to the lungs that results in shortness of breath, and respiratory distress (a condition that occurs when the body needs more oxygen than it's getting, leading to difficulty breathing, rapid breathing, and low blood oxygen levels) and a history of pneumonia (a severe respiratory infection that results in shortness of breath and difficulty breathing) by failing to: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate treatment and services to care for two of three sampled residents (Resident 65 and Resident 36) with indwelling catheter (a thin, flexible tube inserted into the bladder to drain urine and left in place for a set amount of time). Resident 65 and 36 with indwelling catheter was observed with presence of sediments (particles free floating in urine that could be sign of infection) in the urine that was not assessed, documented and reported to the physician. These failures had the potential to result in a delay in treatments, interventions, and services to treat a possible UTI (an infection in the urinary tract- urethra, bladder, utterer and kidney), which could lead to a resident ' s increased confusion, sepsis (a life-threatening blood infection), hospitalization, and possibly death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the nurse staffing information was posted in a highly visible and prominent place that was readily accessible to residents, staff, and visitors daily. This failure had the potential to result in residents and visitors not being able to access full view the facility's staffing information to ensure safe staffing sufficient staffing were implemented.

Inspectors wroteBased on observation, interview, and record review, the facility failed to safely and properly store medications and biologicals that were labeled and not expired in one of two medicaton cart and one on one medicaton room observed in accordance with the facility ' s policy and procedure titled Medications Storage in the Facility by failing to: 1. Remove thirteen (13) pieces of expired Tylenol Suppositories (a pain reliever and fever reducer medication that is designed to be inserted into the anus) from the shelf in the Medication Storage Room in Station 1. 2. Remove an expired container filled with Ondansetron HCL (a drug to treat nausea and vomiting) oral tablet 4 milligrams (unit of mass) from the Medication Cart 2. 3. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to develop a system to systemically identify adverse events (a harmful and negative outcome that happens due to improper medical care), monitor, investigate, analyze root cause, implement and evaluate its Quality Assurance and Performance Improvement Program (QAPI, a program that is focused on action plan to correct identified quality deficiencies [a deviation in performance resulting in an actual or potential undesirable outcome, or an opportunity for improvement]) related to respiratory care for one of three sampled residents ( Resident 77). [...]

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to ensure one of the 18 sampled residents (Resident 48) received his meal tray at the same time with other residents that were sitting in the same table. It was not until 20 minutes later Resident 48 received his meal tray and was eating by himself. This deficient practice violated the rights of Resident 48 to have dignified, equal care and potentially cause emotional distress, loss of appetite, and further affect or damaged to (his, her) health condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the call light (a system that alerts the nursing home staff to the needs of a resident) for 2 of two sampled residents (Resident 45 and Resident 46) who were lying in bed was within reach. This deficient practice had the potential to increase the resident ' s risk of falls, heighten the resident ' s anxiety (fear of the unknown) from not being able to easily call for help, and worsen the resident ' s medical condition due to delayed care.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that one of three sampled residents (Resident 46), was free from the use of physical restraints (anything that inhibits the resident freedom of movement (any change in place or position for the body or any part of the body that the person is physically able to control) and staff convenience. Resident 46 was observed from 11AM to 2:35PM on 12/3/2024 to in a Geri Chair (Geriatric chair a specialized chair with large pad and with wheels designed to assist seniors with limited mobility) with lap table attached to the Geri chair that the resident could not easily remove. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of six sampled residents (Residents 35) preadmission screening and annual resident review (PASARR - a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) assessment screening was complete to determine the facility's ability to provide the special need of the residents. This deficient practice placed the resident at risk of not receiving necessary care and services they need.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan as indicated in the facility ' s policy and procedure and physician ' s order for two of two sampled residents (Resident 54 and Resident 16) by failing to: Develop a plan of care for Resident 54 who had a history of thrombocythemia (a disease that caused the body to many too many platelets) and received antiplatelet therapy (medications that prevent blood clots from forming in arteries [tubes that connect to the heart, which distributes oxygen rich blood to the body] and heart by making platelets [disc-like cells that help stop bleeding, form clots, and helps wounds to heal] less sticky. Develop a plan of care for Resident 16 who exhibited the behaviors of agitation, screaming/yelling, and attempted to hit staff. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 54) was provided care and services for the infected nails by consulting the Dermatology (medicine specialized in treating skin, hair and nails) and Podiatry (medicine specialized in treating foot, ankle, and related structures of the leg) every 2 months and as needed for mycotic (fungal infection that affected the fingernails or toenails) and hypertrophic (nails that are abnormally thicken or misshapen) of the fingernails as ordered by the physician and in accordance with the plan of care. Resident's 54 ' s bilateral fingernails were observed thickened, dry, brittle, and broken after being caught in a blanket. This failure resulted in the resident's nails to fall off and progressive severe infection and pain or discomfort that could lead to hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents who were admitted to the facility with intact skin did not develop a pressure injury to skin and underlying tissue resulting from prolonged pressure on the skin or bony prominences) for one of three sampled residents (Resident 22) who had Stage 3 pressure injury (is a wound where the skin is completely broken, and the damage extends into the deeper layers of tissue beneath it) was not kept clean to prevent recurrent pressure injury. This failure resulted in delayed healing and reopening of the healed pressure injury on the sacrum (a triangular-shaped bone located at the base of the spine, forming the posterior wall of the pelvis).

Inspectors wroteBased on interview and record review the facility failed to ensure residents who have a Gastrostomy Tube (GT, a tube surgically inserted into the stomach or small intestines used to deliver fluids and medications) receive treatment and services to prevent complications such peritonitis (redness and swelling (inflammation) of the lining of the abdomen, and perforation (a small hole) in the peritoneal (lining of the abdominal cavity) and spillage of gastric (acidic fluid in the stomach) contents in the abdominal tissue) for one of three sampled residents (Resident 1) who had GT placed since 2/2024, that the resident pulls out due to confusion. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that Licensed Vocational Nurse (LVN) 6 had the appropriate competencies and skills set to provide nursing care, which included assessing, evaluating, intervening timely and responding to one of three sampled residents (Resident 77) experiencing respiratory distress (trouble breathing often having to work harder to breathe or are not getting enough oxygen) associated with COPD. This failure resulted in the resident condition to decline and resulted in death.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to implement appropriate behavior management and interventions to address the resident's behavioral of agitation, yelling, and attempts to hit staff for one of 2 sampled residents (Resident 16) by failing to: Ensure that care and services were person-centered, aligned with the resident's goals, and maximized their dignity, autonomy, privacy, socialization, independence, choice, and safety. Ensure direct care staff did not consistently interact and communicate in ways that supported the resident's mental and psychosocial well-being. This deficiency could have the potential to result in the failure to implement appropriate behavior management interventions to address the resident's behavioral challenges and support their mental and psychosocial well-being.

Inspectors wroteBased on interviews and records review, the facility failed to ensure one of three residents (Resident 16) was free from unnecessary medications by failing to ensure the resident does not receive Ativan (a medication used to relieve anxiety (severe fear of the unknown) by failing to document the justification for the continued use of Ativan PRN ( as needed) beyond the 14-days limit. These deficiencies have the potential to result in the use of unnecessary medication, that could lead to adverse reaction (undesired outcome of the medication use).

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer medications to two of three sampled residents (Resident 45 and Resident 61) as prescribed by the physician during a medication administration observation that resulted in 7.14 % medication error rate by failing to ensure: 1. Resident 45 was administered vitamin D3 (a vitamin supplement to help prevent bone disorders) oral (given by mouth) tablet 25 micrograms (unit of measurement) via G-tube (a small, flexible tube that's inserted through the stomach wall and into the stomach to deliver nutrition, fluids, and medicine) to 2. Resident 61 was administered multivitamin supplement oral (given by mouth) tablet by mouth.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide one out of 3 sampled residents (Residents 76) with drinks that accommodated the resident ' s preferences. This deficient practice had the potential to result in decreased fluid intake and can lead to dehydration (not having enough fluid in the body).

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the attending physician (Medical Doctor [MD] 1) included blood sugar monitoring [an intervention that is essential for managing diabetes that involves checking blood sugar levels using a device] and medications to manage Diabetes Mellitus [DM, a chronic disease where a person has high blood sugar levels because the body does not produce insulin (a hormone made by the pancreas- an organ in the body) normally] for one of three sampled residents (Resident 1) who was diabetic (a person with diagnosis of diabetes) by failing to: 1. Ensure the licensed staff reviewed Resident 1's general acute care hospital (GACH 1) records for all appropriate discharge orders and ensure admission orders from the facility and continuity of care for DM was verified with MD 1, upon admission to the facility, on [DATE]. 2. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure one of three sampled residents (Resident 1) who had a diagnosis of Diabetes Mellitus [DM, a chronic disease where a person has high blood sugar levels because the body does not produce insulin (a hormone made by the pancreas- an organ in the body) received treatment and services, in accordance with professional standards of practice, the care plan, physician orders, and the facility ' s policies and procedures, for the treatment and care of DM. The facility failed to: 1. Ensure a licensed staff reviewed Resident 1 ' s medical history of DM and discharge orders from GACH 1 that indicated Resident 1 was receiving insulin and blood sugar monitoring, prior to admission to the facility and verify with MD 1 if blood sugar monitoring and/or insulin should be continued while residing at the facility from [DATE] to [DATE]. 2. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the attending physician (Medical Doctor [MD] 1) assessed and evaluated the total program of care for one of three sampled residents (Resident 1) who was diabetic (a person with diagnosis of diabetes) by ensuring the resident ' s blood sugar was monitored [an intervention that is essential for managing diabetes that involves checking blood sugar levels using a device] and Lispro ( a medication that lowers the blood sugar level) to manage Diabetes Mellitus [DM, a chronic disease where a person has high blood sugar levels because the body does not produce insulin (a hormone made by the pancreas- an organ in the body) was not administered while under the physician ' s care in the facility from [DATE] to [DATE] ( a total of 61 days). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility ' s pharmacy consultant thoroughly reviewed and reported irregularities to the attending physician and the facility ' s medical director and Director of Nursing (DON) during Medication Regimen Review (MRR-a structured, critical examination of a person's medicines of the residents to ensure they receive the right medications and monitoring needed to optimize the impact of medicines) for one of one sampled residents (Resident 1) who was admitted to the facility from [DATE] to [DATE] (total 2 months), with diagnosis of Diabetes Mellitus Type 2 (DM, a chronic disease where a person has high blood sugar [glucose] levels) and did not receive insulin that was discontinued without clear indication and blood sugar was not monitored. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that outbreaks of communicable disease are identified and reported to the California Department of Public Health (CDPH) and local public health officer, in accordance with the facility ' s policy and procedure on Communicable Diseases - Outbreak. The facility failed to report a Coronavirus 2019 (COVID- 19, an infectious disease) Outbreak in the facility, to the CDPH within 24 hours of occurrence for five (Residents 1, 2, 3, 4, and 5 of eight sampled residents who tested positive for COVID-19. The facility reported to the local health department on 7/16/2024 but did not notify the CDPH. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility ' s licensed nursing staff met specific annual competencies to skill sets needed to care for a resident ' s respiratory care and services that included respiratory assessments and change in respiratory condition and skills when and how to provide interventions when appropriate for one of two sampled residents (Resident 1). This deficient practice had the potential for Resident 1 to experience a decline in respiratory condition and the potential to delay appropriate treatments and services.

Inspectors wroteBased on observation, interview, and record review the facility failed to document that one of two sampled residents (Resident 1) were provided respiratory treatment and services in the resident ' s medical records. This deficient practice had the potential for serious negative consequences of patient care and overall compliance with the facility ' s policy with potential to result in medical records containing inaccurate documentation.

Inspectors wroteBased on interview and record review, the facility failed to prevent one of two sampled residents (Resident 1), who was a high risk for falls, history of seizures [a sudden, uncontrolled burst of electrical activity in the brain], which can cause changes in behavior, movements, feelings and levels of consciousness), and needed two persons, moderate assistance for transferring, from falling and sustaining injuries by failing to: 1. Develop a care plan and place Resident 1 on seizure monitoring and seizure precautions, upon admission to the facility on 3/2/24, that included the use of seizure pads and floor mats as indicated in the facility's policy and procedures titled Seizure Precautions and Fall Management Program, and bilateral side rails up, in accordance with the physician's order on 3/2/24. 2. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a resident specific comprehensive care plan to (a document that outlines the facility ' s plan to provide personalized care to a resident based on the resident ' s needs) for one of two sampled residents (Resident 1) by failing to: 1. Address appropriate interventions to prevent major injury during recurrent seizure activity (a sudden, uncontrolled burst of electrical activity in the brain that causes uncontrolled movement and loss of consciousness) to one of two sampled residents (Resident 1). 2. Address appropriate interventions for dementia ( a progressive brain disorder that result in memory loss and impairs the thought process). 3. Address appropriate interventions for Resident 1 ' s noncompliance with care and instructions. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure licensed nursing staff did not administer expired insulin (a medication used to treat high blood sugar) to six out of 10 residents (Resident 5, 6, 7, 8, 12 and 14) whose insulin was found to be expired during the inspection of two of two medication carts (Station 2 Medication Cart 2 and Station 1 Medication Cart 1), and ensure Resident 14 ' s Basaglar (Insulin Glargine) KwikPen (prefilled insulin glargine pen) was administered in accordance with manufacturer ' s specifications of once daily and not as a sliding scale. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure expired and discontinued medications were discarded and disposed of properly according to the facility's policy and procedure. 1. The facility failed to ensure expired insulin (a medication used to treat high blood sugar) was removed and discarded for 10 out of 12 residents (Residents 1, 5, 6, 7, 8, 9, 11, 12, 13, and 14) medications reviewed in two of two inspected medication carts (Station 2 Medication Cart 2 and Station 1 Medication Cart 1). (Cross Reference F760) 2. The facility failed to ensure medication remaining at the facility after one of one resident (Resident 10) was discharged from the facility was removed from active supply, marked discontinued and securely stored until destroyed in accordance with the facility ' s Policy and Procedure (P&P) titled, Discontinued Medications, dated 1/2022. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to post accurate nurse staffing information of actual hours worked by the licensed and unlicensed nursing staff directly responsible for resident care per shift daily and was not posted in a prominent location readily accessible to residents and visitors for viewing in accordance with the facility ' s policy and procedure titled Nursing Department - Staffing, Scheduling and Posting. This deficient practice of posting inaccurate nurse staffing information could mislead the residents and visitors that may affect the quality of nursing care provided to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess the medical need and evaluate the risks of entrapment for the use of full-length bed side rails for seven of 15 sampled residents (Resident 2, 9, 10, 11, 12, 13, and 14). These deficient practices placed the residents at risk for potential accident such as a body part being caught between the rails, falls if a resident attempts to climb over, around, between, or through the rails.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident was free from physical restraints, when Certified Nurse Assistant (CNA) 1 placed both full length side rails up of the bed to prevent one of three sampled residents (Resident 2) from getting out of bed, without a physician ' s order and ongoing assessments, in accordance with the facility policy and procedure on Bed Rails and Restraints. This deficient practice had the potential to place Resident 2 for accidents, injury and decline in physical functioning due to the use of bed side rails on both sides of the bed, without physician orders and ongoing assessment. In addition, this deficient practice had the potential to cause depression, feelings of imprisonment and loss of dignity and respect.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a system was in place to provide a safe resident environment for residents who smoke and for residents who do not smoke. The facility failed to identify smoking hazards for (8) eight of (8) sampled residents (Residents 1, 2, 3, 4, 5, and 6) who uses a non-smoking designated area at the facility ' s courtyard patio to smoke and failed to ensure residents (Residents 7 and 8) who do not smoke and was on continuous oxygen use were kept safe, comfortable and free from the hazards of second hand smoke, as indicated in the resident ' s written plans of care and the facility ' s policy and procedure on Smoking. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop resident-centered care plan for one of six sampled residents (Resident 6). Resident 6 did not have a care plan for smoking. This deficient practice had the potential for care and services to be delayed based on the specific needs of the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate the need for three of four sampled residents (Resident 59 and 38) by ensuring the resident's call light device (an alerting device for nurses or other nursing personnel to assist a resident when in need) was within reach ((Resident 59 and 38). As a result of this deficient practice the residents are at risk of not receiving the care and needed especially during an emergency and a potential decline in the resident's activities for daily living, self-esteem, and self-worth.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for the use of psychotropic medications (medications that affects mood and behavior) for four of four sample residents (Resident 25, 63, 40 and 41). The facility failed to: 1. For Resident 25 a plan of care was not developed while receiving psychotropic (medications that affects mood and behavior) medications. 2- For Residents 63 and 40 a plan ofa care was not developed for smoking and saafety. 3. For Resident 41 a plan of care was not developed to address weight loss. These deficient practices put the residents at risk for not receiving necessary care and services to achieve their highest potential.

Inspectors wroteBased on interview, and record review, the facility failed to ensure its residents with limited range of motion (ROM - movement of the joints) receive appropriate treatment and services to increase, prevent, or maintain the ROM mobility for three of four residents (Resident 59, 38 and 48) with the physician's orders for Restorative Nursing Assistant (RNA) assisted exercises. 1. Residents 59 did not receive RNA assisted exercises from 11/1/23 to 11/24/23 (a total of 24 days), 2. Resident 38 was not provided RNA assisted ROM exercises from 11/1/2023 to 11/24/2023 as (a total of 24 days) ordered by the physician. 3. Resident 48 was not provided RNA assisted ROM and AAROM exercises from 11/1/2023 to 11/24/2023 as (a total of 24 days) ordered by the physician. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 63 and Resident 40) were assessed to safely smoke in the facility. 1. Resident 63 did not have a smoking assessment completed. 2. Resident 40 did not have a smoking assessment completed. This deficient practice had a potential to cause a fire hazard and /or injuries caused by unsafe smoking.

Inspectors wroteBased on interview and record review the facility failed to ensure the pharmacy consultant accurately identify and report irregularities to the attending physician and facility's medical director and the Director of Nursing (DON) during the drug regimen review for 5 of 5 sampled residents (Residents 30, 44,18 ,59 and 25). The pharmacy consultant failed to identify the irregularities in the following residents receiving psychotropic (medications that affects mood and behavior) medications. 1a. Resident 30 received Seroquel (an antidepressant or medication used to treat depression [a feeling of severe sadness and hopelessness]) for mood/agitation as ordered by the physician. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to monitor the presence of the resident's target behaviors to justify the continued use of an antipsychotic medication (a medication used to treat psychosis or mental illness) and its adverse effects (side effects) daily, as indicated in the facility's policy and procedure on Psychotherapeutic Drug Management and Guideline for Psychotherapeutic Medications, for four of four sampled residents (Resident 30, 44, 25 and 18). 1. Resident 30 was taking Seroquel ( a medication used to treat mood and agitation). The target behavior manifested by mood and agitation and its corresponding side effects were not monitored November and December 2023, as indicated in the physician's orders. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store foods in the refrigerator. These deficient practices had the potential to result in residents being exposed to food borne illnesses.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement, monitor, and evaluate identified Quality Assurance and Performance Improvement Program (QAPI, a program that is focused on action plan to correct identified quality deficiencies (a deviation in performance resulting in an actual or potential undesirable outcome, or an opportunity for improvement) relating to residents receiving psychotropic (a drug that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) and with skin breakdown. The facility failed to: 1. Documented evidence the QAPI program implemented a plan to ensure the drug regimen irregularities were identified accurately and reported to the physician, the medical director and Director of Nursing (DON) from the month of November 2023 to December 2023 by the pharmacy consultant. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed implement the facility's policy and procedure on infection control to prevent spread of infection by ensuring 1. nasal cannula (NC) tubing (a device used to deliver supplemental oxygen placed directly on a resident's nostrils) and humidifier is changed weekly in accordance with the facility's policy and procedure for Oxygen Administration for one of 3 sampled residents (Resident 30). 2.the nasal cannula (NC-a device used to deliver supplemental oxygen to people) tubing was not touch the floor for two of 10 sampled residents (Resident 68 and Resident 170)' This deficient practice has a potential for 1. Resident 30 and other potential residents receiving oxygen therapy to develop an infection associated. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide education regarding the risks and benefits and side effects (undesired effect) of influenza or flu vaccine (a medication administered via injection to prevent particular kinds of flu viruses that causes flu [a contagious respiratory illness]) prior to the administration of the flu vaccine for four of five sampled residents (Resident 10, Resident 45, Resident 46, and Resident 59). This deficient practice violated the resident or responsible party's rights to make an informed decision.

Inspectors wroteBased on observation, interview and record review, the facility failed to assess and provide on-going activities, based on resident's preferences, interests and support the physical, mental and psychosocial (mental and emotional) well-being of two of six sampled residents (Resident 6 and Resident 59). This deficient practice had the potential for the resident's quality of life to decline and not to meet the residents highest practicable psychosocial well-being of the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to assess, monitor, and intervene to prevent skin breakdown for one of four sampled resident (Resident 6). Resident 6 was observed with an arterial wound (a wound due to lack or decreased blood flow of the arteries on the foot) on the right second toe with dry scab covering the wound that was not previously identified by the facility. A bed cradle (a frame installed at the foot of the bed to keep sheets/blankets off legs/feet) was not used for Resident 6 as ordered by the physician for wound prevention and management. As a result of this deficient practice Resident 6 did not receive wound treatment and monitoring that could result in worsening and development of new skin breakdown.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received the correct amount of gastrostomy tube (GT - an opening to the stomach from the abdominal wall made surgically for the introduction of food) feeding formula for one of three (3) sampled residents (Resident 30). This deficient practice placed the resident at risk for weight control problems and hydration problems (a harmful reduction or increase in the amount of water in the body).

Inspectors wroteBased on observation, interview, and record review, the facility failed to medically related services by failed to coordinate the care with the hospice agency (an agency in charge end of life concern) for one of three sampled residents (Resident 23) who was under hospice care, to ensure the resident received services to renew the identification card Medi-Cal card (a government funded medical insurance). This deficient practice had the potential to negatively affect the resident's psychosocial well-being and delay the delivery of care services to Resident 23.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) who was alert, oriented to name, place, time and person, and able to make needs known was free from sexual abuse (non-nonconsensual touching of one person for the sexual gratification of another) by failing to ensure: 1. Resident 1 was not sexually abused by the Laundry Staff from 8/30/23 to 9/1/23. 2. Resident 1 was protected from sexual abuse from the Laundry Staff. The Licensed Vocational Nurse (LVN 1) and the Director of Nursing (DON) was aware of Resident 1's allegation of sexual abuse when it was reported by Resident 1 on 9/2/23. The Laundry Staff continued to work in the facility until 9/5/23. [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to implement the facility's policy and procedure, titled Abuse Prevention and Prohibition Program Policy for one of three sampled residents (Resident 1) by not protecting, preventing, reporting, investigating an allegation of sexual abuse (non-consensual touching of one person for the sexual gratification of another) from the facility's male Laundry Staff. The facility failed to: 1. Prevent Resident 1 from sexual abuse when the facility's male Laundry Staff grabbed and rubbed Resident 1's hand between his belt buckle and his penis five to six times back and forth while in the Resident 1's room on 8/30/23 and 8/31/23. 2. Protect Resident 1 from sexual abuse on 9/1/23, when the Laundry Staff continued to go into Resident 1's room putting the resident's hand above his penis. [...]

Inspectors wroteBased on interview, record review, the facility failed to ensure Certified Nurse Assistant (CNA) 5 received training on abuse prevention and reporting prior to performing resident care at the facility. This failure had the potential to result in failure to identify or report abuse and result in emotional distress to one of three sampled residents (Resident 1) as indicated in Resident 1 ' s care plan and in accordance with the facility ' s policy on Orientation Program for Newly Hired Employees, Transfers, Volunteers.