Golden Pavilion Healthcare

Inspectors wroteBased on interview and record review, the facility failed to report a resident-to-resident abuse allegation to California Department of Public Health (CDPH, state survey agency) and the Ombudsman's Office (an advocacy organization who protect the rights, health, and welfare of residents in long-term care facilities) within two hours, as required. This failure had the potential to leave residents in the facility vulnerable to further abuse. Review of the document titled Report of Suspected Dependent Adult/Elder Abuse (SOC 341), dated 6/10/26, submitted by the facility to CDPH on 6/10/26 at 3:26 PM, indicated that Resident 1 reported that on the night of 6/9/26, Resident 2 requested assistance, and when Resident 1 was unable to understand the request, Resident 2 struck Resident 1. [...]

Inspectors wroteBased on interviews and record review, the facility failed to provide adequate supervision for one of two sampled residents (Resident 3) when Resident 3 exited the facility with Resident 4 without the facility's knowledge or supervision. This failure placed Resident 1 at risk of injury or harm. Resident 3 was admitted on [DATE] with diagnoses including abnormal posture and abnormalities of gait and mobility (changes in walking or movement, such as limping, shuffling, or losing balance). Resident 3 was discharged on 6/29/26. Review of Resident 3's minimum data set assessment (MDS, a federally mandated resident assessment tool), dated 6/5/26, indicated moderate cognitive impairment (noticeable changes or decline in memory or thinking) and use of a walker or cane for ambulation. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent an avoidable fall for one of one sampled resident (Resident 1) when Resident 1 fell off the bed to the floor. This failure resulted in Resident 1's fall with fractures to the left humerus (the long bone in the upper arm that goes from the shoulder to the elbow) and left distal femur (lower part of thigh bone found behind the kneecap [bone located at the front of the knee]). Review of Resident 1's admission Record indicated, Resident 1 was readmitted on [DATE], with diagnoses including unspecified injury of left and right thigh, type 2 diabetes (a disease that occurs when your blood sugar is too high), muscle weakness, and history of transient ischemic attack (TIA, a mini-stroke caused by temporary blockage of blood flow to the brain). [...]

Inspectors wroteBased on interview and record review, the facility failed to include one of one sampled resident (Resident 1) and her representative in developing Resident 1's comprehensive care plan when there were no interdisciplinary team (IDT, a group of health experts including doctor, nurse, therapist, social worker, dietitian and activity staff) meetings conducted after completion of Resident 1's assessments for quarterly review and significant change of condition due to fall with injuries. This failure violated Resident 1's right to participate in planning for her care. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe environment free from potentially serious accident hazards for all residents when its policies and procedures were not implemented for the following practices: 1. The facility failed to implement their smoking policy and procedures (P&P) when it allowed one (1) of 11 residents (Resident 88) who smoked in the facility to keep in possession of their own lighters and cigarettes inside the resident care area. 2a. The facility failed to provide adequate supervision to prevent accidents when Resident 225 was left unsupervised while smoking, and was later found at a nearby facility. This deficient practice placed the resident at risk for injury and unsafe wandering/elopement.2b. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) received tube feeding (a method of delivering liquid nutrition, fluids, and medication directly into the digestive system through a feeding tube when a person cannot eat or drink enough by mouth) in accordance with physician order, the comprehensive person-centered care plan, and the resident's goals when Resident 1's tube feeding rate was increased from 60 to 200 mL/hr (milliliters per hour, which is a unit of measurement for a flow or infusion rate). This failure resulted in Resident 1 transferring to a local acute care hospital and eventually passing away due to aspiration pneumonia (a lung infection. It happens when food, liquid, or vomit is breathed into the airways or lungs instead of being swallowed, leading to inflammation and a potential bacterial infection. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to provide an environment free from accident hazards for Resident 1, one of three sampled residents, when Resident 1 eloped from facility, twice, in the middle of the night, in her nightgown, exposing resident to risk of accidents, injury, or harm. The facility failed to supervise, protect, and monitor residents in their care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of one of 3 sampled residents (Resident 1) when a scheduled fentanyl patch (a medicated adhesive patch that delivers fentanyl, a strong opioid painkiller, through the skin) was not applied to Resident 1 on 5/30/25 at 9 AM on time. This failure was likely to result in putting Resident 1 at risk for not meeting her pain control need.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary condition was met for food storage in the kitchen when there were expired strawberry topping and sliced turkey in the refrigerator. These failures had the potential to result in putting residents at risk for foodborne illness (a disease caused by consuming contaminated food or drink).

Inspectors wroteBased on observation, interview, and record review, the facility failed review and revise the care plan to include pain management for Resident 525. This failure resulted in Resident 525 experiencing pain leading to discomfort.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 30) received the necessary behavioral health care and services to attain or maintain the highest practicable mental and psychosocial well- being in accordance with the comprehensive assessment and plan of care. This failure resulted in Resident 30 having loud verbal outbursts, using foul language, inappropriate hand gestures when interacting with staff and other residents, including Resident 30 throwing urine at his roommate.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control program and practices designed to help prevent the development and transmission of diseases and infections when the PICC (Peripherally Inserted Central Catheter: a long, thin, flexible tube inserted into a vein, usually in the arm, and advanced to a larger vein near the heart. It provides access to the bloodstream for delivering medications, fluids, and blood draws for a prolonged period, reducing the need for frequent needle insertions.) line dressing was overdue to change for one of 2 sampled residents (Resident 380). This failure had the potential to develop infection in Resident 380.

Inspectors wroteBased on interview and record review, the facility: 1. Did not ensure prescribed medication for Resident 1 was available on the scheduled administration time on 3/18/25 at 4:00 PM, and 3/19/25 at 12:00 AM and 8:00AM. 2. Did not properly account for the receipt of the controlled medication (drugs or substances that are regulated by the government due to their potential for abuse and addiction) (diazepam- a controlled substance to treat anxiety, muscle spasms, and seizures) for Resident 1. These failures resulted in the potential for reduced effectiveness to prevent a worsening of symptoms or flare-ups of muscle spasms or increased physical discomfort related to complex regional pain syndrome or potentially leading to anxiety or mood swings. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate assessment of the Minimum Data Set (MDS, a standardized assessment tool) for one of three sampled residents (Resident 1) when the MDS did not document dementia (decline in memory or other thinking skills), fracture (broken bone) and osteopenia (bone density loss, weak bones) as active diagnoses. The facility failure resulted to inaccurate MDS to reflect Resident 1's current health status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the physician (Medical Doctor, MD) order for one of three sampled resident (Resident 1) when the splint (a supportive device to immobilize [to stop or reduce movement] and protect a broken bone) was not applied to the fractured left forearm. The facility failure had the potential for Resident 1 to develop complication and further resident harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to thoroughly investigate a change in condition for one of three sampled resident (resident 1) when Resident 1 developed bruises to the left forearm and on top of the left hand with unknown origin. The facility failure has the potential for Resident 1 to not receive the necessary care and services.

Inspectors wroteBased on interview and record review the facility failed to develop a comprehensive plan of care for one of three residents (Resident 1) when osteopenia (bone density loss, weak bones) was not addressed. The facility failure has the potential for Resident 1 to not receive necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to train and review the performance of three out of three sampled Certified Nursing Assistants (CNAs) when employee files of CNA 1, CNA 2, and CNA 3 lacked documentation of initial training as well as a performance review required by facility policy and procedure. This failure has the potential to result in untrained CNAs providing unsafe care that could cause harm to Residents.

Inspectors wroteBased on interview and record review, the facility failed to retain personal possessions of Resident 1, one of two sampled residents, when after return from hospitalization Resident 1's two head phones, one Blue Tooth speaker/microphone and two full Lysol disinfectant spray cans were missing from his closet. This failure resulted in depression, disappointment, and mental anguish to the resident.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from neglect when Resident 1, one of two sampled residents, was deprived of care and did not receive a sponge bath for one month. This failure resulted in discomfort, humiliation, and embarrassment to the resident.

Inspectors wroteBased on interview and record review, the facility failed to provide prn medication (as needed) on time to Resident 1, one of two sampled residents, when the resident waited for pain relief caused by pressure ulcer (wound infection in lower back) and bone infection. This failure caused the resident unnecessary pain, discomfort, and anxiety.

Inspectors wroteBased on interview and record review, the facility failed to report an investigation, and results, related to abuse, neglect or mistreatment, when Resident 1, one of one sampled residents, was injured when she was dropped on the floor and her tooth was broken. For alleged violations of neglect or mistreatment that do not result in serious bodily injury the facility must report the allegation no later than 24 hours. The facility must provide in its report sufficient information to describe the alleged violation and indicate how residents are being protected. Within 5 working days of the incident, the facility must provide sufficient information to describe the results of the investigation and indicate any corrective actions taken. Any updates should be included. This failure showed no action was taken for the injury to the Residents tooth. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Resident 1, one of one sampled resident, was assisted to obtain or was reimbursed for eyeglasses after staff lost three pairs of residents prescription eyeglasses. Resident has glaucoma and vision difficulties. This failure resulted in creating depression and additional visual difficulties for the resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure foot care (podiatrist service) was provided to Resident 1, one of one sampled resident, when she did not receive any foot care service, e.g,, toe nail clipping, since admission, for 2 1/2 years, and has a condition that poses a risk to foot health (e.g., diabetes) this resulted in immobility, and overgrown, uncomfortable toe nails and feet. This failure resulted in neglect to the resident, caused pain, and loss of ability to walk.

Inspectors wroteBased on interview and record review, the facility failed to assist Resident 1, one of one sampled resident, to obtain dental care for a facility caused tooth injury, due to fall, for nine months. Facility must refer resident promptly, within 3 days, for dental services. This failure resulted in lack of care and services for nine months to resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure the result of its investigation of the abuse allegation involving two residents (Resident 1 and Resident 2) on 1/29/24 was reported within five working days of the occurrence of the alleged incident to the State Survey Agency. This failure violated the federal mandated reporting time frame.

Inspectors wroteBased on interview and record review, the facility failed to treat Resident 1, one of one sampled resident, with dignity and respect when resident waited on the nurse call light over one hour for pain medications on two successive evenings and failed to provide pain management relief, in a timely manner when resident waited over an hour for pain medication for his leg wound on two occasions during the evening shift. This failure caused the resident pain and suffering, violation of his rights and decreased feelings of well-being.

Inspectors wroteBased on interview and record review, the facility failed to provide pain management relief, in a timely manner, for Resident 1, one of one sampled resident, when resident waited over an hour for pain medication for his leg wound on two occasions during the evening shift. This failure resulted in unnecessary pain and suffering and decreased feelings of well-being for the resident.

Inspectors wroteBased on interviews and facility policy review, the facility failed to implement their Legionella (a pathogenic gram-negative bacteria) water management program. This had the potential to affect all 229 residents residing in the facility.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure confidential medical information was kept private for 1 (Resident #185) of 4 sampled residents reviewed for dignity. Specifically, the facility failed to remove visible wristbands that identified medical information about the resident after Resident #185 was readmitted from the hospital.

Inspectors wroteBased on record review, interviews, and facility document and policy review, the facility failed to report an allegation of physical abuse involving 1 (Resident #197) of 4 sampled residents reviewed for abuse to the California Department of Public Health (CDPH) within two hours.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected the use of an antipsychotic medication and physical behaviors directed towards others for 1 (Resident #197) of 2 sampled residents reviewed for behaviors and accurately reflected the discharge location for 1 (Resident #237) of 3 sampled residents reviewed for discharges.

Inspectors wroteBased on interview, record review, and facility document and policy review, the facility failed to complete a new Level I Preadmission Screening and Resident Review (PASARR) after residents were diagnosed with a new mental illness for 2 (Resident #41 and Resident #164) of 4 sampled residents reviewed for PASARR requirements.

Inspectors wroteBased on interviews, record review, facility policy review, and review of the California Department of Health Care Services Preadmission Screening and Resident Review (PASRR) Level I Assessment Guide, the facility failed to ensure a Level I Preadmission Screening and Resident Review (PASARR) was accurately completed for 1 (Resident #139) of 4 sampled residents reviewed for PASARR requirements. Specifically, the facility failed to ensure Resident #139's Level I PASARR Screening reflected the presence of a serious diagnosed mental disorder.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to ensure staff administered medication as ordered by the physician for 1 (Resident #180) of 1 sampled resident reviewed for medication concerns.

Inspectors wroteBased on observations, record review, interviews, and facility policy review, the facility failed to ensure they posted the total number of and the actual hours worked for licensed and unlicensed nursing staff directly responsible for resident care per shift, which included registered nurses (RN), licensed practical nurses (LPN) or licensed vocational nurses (LVN), and certified nurse aides (CNA) and failed to post this information at the beginning of each shift in a prominent place readily accessible to residents and visitors. This had the potential to affect all 229 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised based on the needs of the resident and in response to current interventions for one of five sampled residents (Resident 1). This deficient practice does not ensure plan of care was evaluated for effectiveness to prevent reoccurrence of physical aggression that could result to harm or serious injury to other residents and staff.

Inspectors wroteBased on observation, interview and record reviews, the facility failed to provide goods and services such as the call lights to three residents to meet their needs by its staff when: 1) Resident 1, Resident 2 and Resident 3 were found to have their call lights not within reach and was found disconnected from the wall socket. 2) The facility did not ensure an orientation and training was implemented on general guidelines in answering the call light. These failures will result to an environment that promotes neglect. Neglect occurs when the facility is aware of, or should have been aware of, goods or services that a resident(s) require but the facility fails to provide them to the resident(s) resulting in, or may result in, physical harm, pain, mental anguish, or emotional distress.

Inspectors wroteBased on interview and record review the facility failed to develop a comprehensive care plan for the two residents that included measurable objectives and specific interventions when: Resident 1. The call light in Resident 1's room (all three beds) was found disconnected from the wall socket and was not within the residents' reach. Resident 2. Had a resident to resident altercation. Resident B was the abuser. No care plan was developed for this resident-to-resident abuse. This failure has the potential for not meeting the residents' goals of care to meet their highest practicable well-being.

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to ensure the allegation of resident-to-resident abuse was promptly reported to the State Agency (SA, which is the California Department of Public Health, CDPH) in accordance with the facility's policy and procedure for two of four sampled residents (Residents 2 and 3). Failure to promptly report allegation of abuse had the potential for further abuse to happen and thereby increasing the chances of harm to the residents.

Inspectors wroteBased on observation interview and record the facility failed to ensure the accuracy of assessment for one of four (4) sampled residents (Resident 1) when the Quarterly Minimum Data Set (MDS, as assessment tool) dated 9/27/23, did not reflect the Residents 1's on-going chronic pain. This deficient practice had the potential to delay the delivery of care and could result in the decline in resident's condition.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Medication Drug Regimen (also known as Drug Regimen Review [DDR], a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) for one of four (4) sampled residents (Resident 1), who received as needed doses of Hydromorphone (strong opioid-based pain medicine), were reviewed for drug irregularities when: 1. The facility consistently administered as needed doses of Hydromorphone for chronic muscular pain without conducting a thorough Drug Regimen Review (DRR). Without proper evaluation, there was a lack of oversight on the frequency and appropriateness of administering Hydromorphone. [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent unnecessary use of medication for one of four (4) sampled residents (Resident 1) when: 1. The facility failed to monitor and assess the effectiveness of the pain management regimen for Resident 1. Despite ongoing complaints of pain, there was no indication of adequate monitoring or adjustment to the medication regimen. This lack of monitoring resulted in the persistence of the resident's pain, indicating a failure in the overall management of the medication regimen. Resident 1 felt pain was still staying even after the doses of the pain medication were administered, it was there all the time, it never goes away. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide one of 47 sampled residents (Resident 2) access to communication with staff and visitors in a language that is clear and understandable to the resident when a language translation service was not available for use by the resident. This deficient practice resulted in Resident 2 feeling frustrated for being unable to communicate with staff and relaying his needs and concerns and had the potential for the 47 residents with limited proficiency in English to not have access to communication with persons inside and outside the facility.

Inspectors wroteBased on interview and record reviews, the facility failed to notify the resident representative (RP) of one of three sampled residents (Resident 1) when Resident 1 had a fall incident and a discoloration on his left forearm. This deficient practice prevented Resident 1's representative in participating in the planning and decision-making of care and services rendered to the resident after the facility became aware of the incidents.

Inspectors wroteBased on interview and record review, the facility failed to bathe or provide shower to one of four sampled residents (Resident 3) for 12 days from 10/5/23 to 10/17/23. This failure may lead to Resident 3's breakdown of skin integrity and accumulation of dirt and bacteria present on the skin's surface, increasing the risk of infection and can negatively impact Resident 3's sense of well-being.

Inspectors wroteBased on observation, interview and record review the facility failed to develop a comprehensive care plan for a resident that included measurable objectives and specific interventions when: Resident 1 's care plan was not updated when there were documentations of her having altercations with different residents in the facility. This failure has the potential for not meeting the resident's goals of care to meet her highest practicable well-being.

Inspectors wroteBased on interview and record review, the facility failed to identify and document, changes in Resident 1 ' s condition when: 1. Resident 1 ' s wound changed to Stage 4. 2. Resident 1 readmitted on [DATE], no skin assessment done. 3. The IDT (Interdisciplinary Team) did not address the changes in condition for Resident 1. These failures had the potential for resident ' s condition not assessed and needs not addressed could result to resident not getting the right treatment and care.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement comprehensive person-centered care plan for one of three residents (Resident 1)when: There was no care plan on 6/10/22 addressing sacral discoloration. There was no care plan on 6/14/22 addressing mid -lower sacrum, coccyx, right and left heel wound . There was no care plan on 6/23/22 addressing the new order for Megesterol acetate (an appetite stimulant). There was no care plan on 7/3/22, when Resident 1 was re-admitted with new Antibiotic order for new Diagnosis of Cellulitis. These failures had the potential to prevent the resident from receiving appropriate and individualized care and services consistent with her needs.

Inspectors wroteBased on interview and record review, the facility failed to follow physician ' s order to obtain weight weekly on admission, and failed to follow facility policy and procedure, as evidenced by no documented weight on day of admission, 3/11/22, week of 3/30/23 and 4/6/23. No Monthly weights for April and May 2022. This failure had the potential for changes in condition not being assessed and identified, resulting in Resident 1 weight loss.

Inspectors wroteBased on interview and record review, the facility failed to demonstrate that they developed, maintained and implemented a training program for four out of four sampled clinical staff (registered nurse [RN] 1, licensed vocational nurse [LVN] 1, certified nursing assistant [CNA] 1, and restorative nurse assistant [RNA] 1) when the facility could not produce documentation of orientation or competency documentation specific to the facility or resident care population for these four sampled staff. This failure has the potential to result in untrained staff that puts residents ' safety at risk.

Inspectors wroteBased on interview and record review, the facility failed to ensure prompt resolution of resident council grievances when two out of two sampled grievances lacked pertinent dates or conclusions/outcomes necessary to demonstrate that grievances are processed effectively, and residents are apprised of progress towards resolution. This failure has the potential for resident council recommendations to not be considered or grievances to go unresolved.

Inspectors wroteBased on interview, and record review, the facility failed to care for resident's need (Resident 2), by not reporting or notifying the physician during change of condition when Resident 1 complained of chest pain and severe abdominal pain. This failure resulted in resident not properly assessed by the physician and not given the right medication and treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure prompt resolution of grievances when two out of two sampled resident grievances lacked pertinent dates or conclusions/outcomes necessary to demonstrate that grievances are processed effectively, and residents are apprised of progress towards resolution. This failure has the potential to result in a residents ' voiced grievances not being heard or resolved.

Inspectors wroteBased on interview and record review, the facility failed to ensure licensed nurses have the specific competencies and skills necessary to care for Residents needs (Resident 2) by not taking or reportingto the physician the baseline vital signs during a change of resident's condition. This failure resulted to not meeting Resident 2's nursing needs and goals to attain the highest practicable well being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that one out of three sampled residents (Resident 1) was free of any significant medication errors when Registered Nurse (RN) 1 crushed an extended-release medication, Metoprolol (a blood pressure lowering medication made to release slowly over time). This failure had the potential to result in Resident 1 receiving a higher dose of a blood pressure medication at one time, increasing the risk for side effects or hypotensive symptoms (effects due to a quick drop in blood pressure).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) was free from verbal abuse when Registered Nurse (RN) 3 told him Get out of my face twice. This failure resulted in Resident 2 stating I still don't feel safe here . during an observation and interview by the surveyor.

Inspectors wroteBased on interview and record review, the facility failed to report the result of the abuse investigation to the California Department of Public Health (CDPH) within 5 working days in accordance with Federal requirements for one of three sampled residents (Resident 2). The alleged abuse incident for Resident 2 occurred on 9/12/23 and the result of facility investigation is not complete during the State Agency investigation visit on 9/21/23. The facility's failure to report abuse according to the required time frame had the potential to delay the identification and implementation of appropriate corrective actions and may place the residents at risk for abuse.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop care plans for two of three sampled residents (Resident 1 and Resident 2) when: 1. There was no care plan developed to address alleged incident of staff verbal abuse to Resident 2 on 9/12/23. 2. There was no care plan developed to address the fall incident on 7/7/23 for Resident 1. This failure resulted to Resident 1's safety needs not being met and Resident 2's psychosocial needs not being met.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident receives adequate supervision to prevent accidents, for one of three residents (Resident 1) when they failed to provide the appropriate level of assistance while transferring. This failure resulted in Resident 1 sustaining an injury to her left forehead, with bruising around her left eye area, from falling forward, while a Certified Nursing Assistant (CNA) was toileting the resident on 7/7/23.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent the development of an avoidable pressure injury for Resident 277, one of three sampled residents with pressure injuries. The facility assessed Resident 277 as high risk for developing pressure injuries (localized damage to the skin and/or underlying soft tissue usually over a bony prominence. A pressure injury may present as intact skin and may be painful). However, the facility failed to implement interventions to off load pressure to Resident 277's heels. As a result of this failure, Resident 277 developed a pressure injury to her left heel on 6/24/21.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe medication storage and distribution practice when: 1. Three of four medication carts (2 [NAME] Team 1, 1 [NAME] Team 2, 2 East Team 1) had loose tablets in the drawers. 2. One of two medication room refrigerators (1 East) had unlabeled medications stored. 3. Four of four medication carts (1 [NAME] Team 1, 2 [NAME] Team 1, 2 East Team 1, 1 [NAME] Team 2), had out of date medications stored. 4. Two of four medication carts (1 [NAME] Team 1, 2 East Team 1) had medications with unreadable label stored. 5. One of four medication carts (1 [NAME] Team 1) had medication labeled refrigerate stored. This failure had the potential for resident to receive wrong medications, contaminated medication, and/or ineffective medication.

Inspectors wrote2b. Based on interview and record review the facility failed to implement its plan of action to correct the identified deficiencies when: 1. Result of the audit logs for baseline care plan (BCP), wound summary, psychotropic medication were not reviewed as indicated in the plan of correction (POC) dated 9/20/21. 2. In-services were not completed as indicated in the POC dated 9/20/21. The facility failure may result in a repeated regulatory noncompliance which had the potential for residents not receive necessary care and services.

Inspectors wroteBased on observation, interview, and record review, facility failed to ensure psychotropic medication is used to treat a specific diagnosis and documented condition for one of three sampled residents, (Resident 102) when: a. Risperdal (an antipsychotic) was indicated for dementia (decline in memory or other thinking skills); b. Consent was not obtained for use of Risperdal; c. There is no specific target behavior monitoring for use of Risperdal. Failure to obtain consent, identify and monitor specific behavior manifestation for the use of psychotropic medication had the potential to put the residents at risk of receiving unnecessary medications that could result in serious harm. Definition: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement infection control and prevention program when: 1.a Registered Nurse (RN) 3 brought out a cup from Resident 375's room which was on contact precautions (infection control and prevention measures used for diseases caused by microorganisms that may be spread easily by contact with the patient's intact skin or with contaminated environmental surfaces). 1.b. Physical Therapy Assistant (PTA) did not: (a) wear appropropriate personal protective equipment (PPE) prior to entering Resident 375's room (b) did not perform hand hygiene after exiting Resident 375's room. 2.a. Licensed Vocational Nurse (LVN) 4 did not perform hand hygiene during dressing changes on 1 of twenty-eight sampled resident (Resident 79). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to complete a Baseline Care Plan (BCP) for one of 42 sampled residents (Resident 276) when there was no evidence of documentation of a completed BCP. A BCP includes minimum healthcare information necessary to properly care for each resident immediately upon their admission, which would address resident-specific health and safety concerns to prevent decline, injury, such as elopement or fall risk, and would identify needs for supervision, behavioral interventions, and assistance with activities of daily living, as necessary. This deficient practice had the potential to result in inadequate care and services rendered to the resident.

Inspectors wroteBased on interview and record review, the facility failed to submit an application for Change of Ownership (CHOW) to the department. This facility failed to meet the state law (Title 22, 72201 (2)) requirement.

Inspectors wroteBased on interview and record review, the facility has no valid contract to provide onsite hospice care. This facility failure has the potential to negatively impact the provision of care for Resident 30. Definition: Hospice care means a comprehensive set of services . identified and coordinated by an interdisciplinary group (IDG) to provide for the physical, psychosocial, spiritual, and emotional needs of a terminally ill patient and/or family members, as delineated in a specific patient plan of care .these services are provided by a Medicare-certified hospice .

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a safe, functional, and clean environment for residents. 1. Beauty salon door was not kept clean. 2. Uncleaned equipment and residents' personal items were stored in the residents' shower room. 3. The eye wash station located in the laundry room was not cleaned. These failures had the potential to not provide a clean and safe living conditions for the residents. 1. During an initial tour observation on 6/22/21 at 8:53 AM, the beauty salon located at the first floor had a sign at the door indicating, In Use, and the entrance door was closed. The door had fixed horizontal slats on the lower panel that had significant accumulation of dust and gray-like fuzzy material. During an interview on 6/22/21 at 8:54 AM, with Housekeeping Aide (HKA) 1, HKA 1 acknowledged the observations and stated, .it's dirty . [...]