Greenfield Care Center of South Gate

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from verbal and mental abuse for two of three sampled residents (Resident 2 and Resident 3). This deficient practice resulted in Resident 1 verbally and mentally abusing Residents 2 and 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered as ordered by the physician for five of five sampled residents (Resident 2, 3, 4, 5, and 6). This failure resulted in residents' delay in receiving prescribed medications, which could lead to adverse drug reactions and ineffective treatment of medical conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 2 disinfected the glucometer (device to measure blood sugar) and blood pressure cuff when used between two of four sampled residents (Resident 3 and Resident 5). This failure had the potential to place the residents at risk for cross-contamination and infections, compromising residents' overall health and safety.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of one Certified Nursing Assistant (CNA) 3 rom registry staffing (temporary contracted staffing) received facility training on abuse prevention prior to providing care to residents. The deficient practice had the potential to place residents at risk for abuse and neglect.

Inspectors wroteBased on interview and record review, the facility failed to notify one of three sampled residents' (Resident 1) responsible party (RP 1), regarding the resident's refusal of shower seven times. This failure resulted in Resident 1's RP 1 not being aware of the resident's refusal of shower and resident's hygiene needs not being assisted and met.

Inspectors wroteBased on interview and record review, the facility failed to ensure non consensual sexual contact (any sexual touching or contact that occurs without the explicit [clear] and voluntary agreement with individuals involved) did not recur for two of three sampled residents (Resident 1 and Resident 2), by failing to:1). Ensure Interdisciplinary Team ([IDT] group of healthcare professionals, including resident/ resident representative, working together to provide residents with needed care) meeting was conducted and plan of care with interventions created after the incident on 6/13/2025 when Resident 2 kissed Resident 1 in Resident 1's room and attempted to climb into Resident 1's bed. [...]

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of sexual abuse (non-consensual sexual contact of any type with a resident) to the California Department of Public Health (CDPH), for one of three sampled residents (Resident 1), when Resident 2 kissed Resident 1, who did not have the capacity to understand and make decisions (consent) and was found lying in Resident 1's bed. This failure resulted in a delay in the investigation by the CDPH and placed Resident 1 at risk for further abuse by Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to investigate an allegation of sexual abuse (non-consensual sexual contact of any type with a resident) for one of three sampled residents (Resident 1), when Resident 2 kissed Resident 1, who did not have the capacity to understand and make decisions (consent), and was found lying in Resident 1's bed. This failure resulted in a sexual abuse not being addressed, resulting in the potential for repeated sexual abuse.

Inspectors wroteBased on interview and record review, the licensed nurse failed to follow physician's orders for two of three sampled residents (Resident 2 and Resident 3) when:1. Resident 2's blood pressure readings and heart rate were not recorded and documented on the Medication Administration Record (MAR), for six days in the month of August 2025 and one day in the month of September 2025.2. Resident 3's arteriovenous fistula (AV fistula, direct connection between an artery and a vein) dressing was not removed four hours after dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) treatment on 9/10/2025 and 9/11/2025.3. Resident 3 was not administered oxygen as ordered at two liters (measurement for gas volume) per minute.4. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect one of three resident's (Resident 1) right to be free from physical abuse by another resident (Resident 2). This deficient practice resulted in Resident 1 being slapped on the right side of the face by Resident 2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control measures were maintained and/or implemented for eight of 19 sampled residents (Residents 71, 70, 74, 1, 18, 52, 5, and 20) when: 1. Signage for enhanced barrier precautions (EBP, infection control measures used to reduce the spread of multidrug-resistant organisms [MDROs], requiring staff to wear a protective gown and gloves during high-contact activity) was not placed outside of Rooms A, B, and C.2. Certified Nursing Assistant (CNA) 2 and CNA 3 did not don the required personal protective equipment (PPE, clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) before entering Room D.3. CNA 1 did not don the required PPE before entering Resident 5's room.4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care plans were developed and interventions implemented for three of 19 sampled residents (Residents 71, 37, and 67). This deficient practice placed Residents 71, 37, and 67 at risk for not receiving the necessary interventions for the services and/or treatments they were receiving.

Inspectors wroteBased on interview and record review, the facility failed to clarify hold parameters (specific instructions that accompany a medication order for safe and effective drug administration) for amlodipine (medication to lower blood pressure) and lisinopril (medication to lower blood pressure) for one of seven sampled residents (Resident 19). This deficient practice had the potential to result in Resident 19 experiencing bradycardia (heart rate less than 60 beats per minute [bpm], a normal heart rate is between 60 to 100 bpm) with symptoms of dizziness, fatigue, chest pain, and/or fainting.

Inspectors wroteBased on observation, interview and record review, the facility did not accommodate the preference to use a urinal for one of 19 sampled residents (Resident 1). This deficient practice resulted in Resident 1 wearing and voiding into an incontinence brief despite being continent, removing his ability to void in a dignified manner. Cross-reference: F-tags F657, F690Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 5/15/2025. Resident 1's admitting diagnoses included pleural effusion (a collection of fluid around your lungs) and pneumonia (lung inflammation caused by infection). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) from the Responsible Party (RP) 2 prior to administering Depakote (an anticonvulsant medication used to treat seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness] and other behavioral conditions) and placing the bed against the wall for one of five sampled residents (Resident 37). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light (a device that residents use to request assistance from staff) was within reach for one of six sampled residents (Resident 82). This deficient practice had the potential to result in delay or an inability for Resident 82 to obtain necessary care and services as needed.

Inspectors wroteBased on interview and record review, the facility failed to timely notify one of three sampled residents' (Resident 81) physician of significant weight loss on 3/17/2025 and 6/3/2025. This deficient practice resulted in a delay in care and services and had the potential to result in further weight loss. Cross Reference F692.

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of financial liability (Skilled Nursing Facility Advance Beneficiary Notice- SNF ABN) to two out of three sampled residents (Resident 13 and Resident 23) when Medicare Part A coverage ended and the residents chose to continue receiving skilled nursing services. This failure had the potential to result in unexpected pay charges for Resident 13 and Resident 23.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Minimum Data Set (MDS, a resident assessment tool) assessments for two of 19 sampled residents (Residents 71 and 81) were accurate. This deficient practice resulted in the transmission of inaccurate data to the Centers for Medicare and Medicaid Services (CMS) regarding Resident 71 and 81's health status. This deficient practice also created the potential for Residents 81 and 71 to not receive the care and interventions needed to reach their highest practicable physical and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to revise the incontinence care plan for one out of 19 sampled residents (Resident 1). This deficient practice placed Resident 1 at risk of not receiving interventions to maintain his continence and dignity. Cross-reference: F-tags F690 and F550Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 5/15/2025. Resident 1's admitting diagnoses included pleural effusion (a collection of fluid around your lungs) and pneumonia (lung inflammation caused by infection). During a review of Resident 1's MDS, dated [DATE], the MDS indicated Resident 1 did not have cognitive impairments, and was dependent on staff for showering, and required substantial to maximal assistance from staff for mobility while in and out of bed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents' (Resident 67) low air loss mattress ([LALM], a mattress designed to distribute body weight over a broad surface area to help prevent skin breakdown) was accurately set to Resident 67's weight. This deficient practice had the potential to cause the avoidable development and/or worsening of pressure ulcers (PU, localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) and the complications associated with impaired skin integrity.

Inspectors wroteBased on observation, interview and record review, the facility applied an incontinence brief and failed to allow use of a urinal for one of 19 sampled residents (Resident 1). This deficient practice placed Resident 1 at risk for being unable to void with dignity into a urinal and maintain his continence (the ability to control movements of the bowels and bladder).

Inspectors wroteBased on interview and record review, the facility failed to reweigh one of three sampled residents (Resident 81) to confirm Resident 81's significant weight loss on 3/27/2025 and 6/3/2025. This deficient practice had the potential to result in improper management of Resident 81's weight. Cross Reference F580.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure oxygen therapy (a medical treatment that provides extra oxygen to breathe, typically prescribed for individuals with conditions causing low blood oxygen levels) was administered as ordered by the physician for two of 19 sampled residents (Residents 71 and 1). This deficient practice placed Resident 71 and Resident 1 at risk of sustaining complications of not receiving enough or receiving too much supplemental oxygen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the facility's policy and procedure (P&P) titled Usage of bedside rails revised 1/2024, which indicated consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for side rail use would be obtained from the resident and/or responsible party (RP-a person who has been legally authorized to act on behalf of a resident in matters to care within the facility), after presenting potential benefits and risks for one of six sampled residents (Resident 12). This deficient practice had the potential to result in inappropriate use of side rails for Resident 12 and could lead to injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure Registered Nurse (RN) 3 documented on the Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) immediately after administering medications to one of seven sampled residents (Resident 19). This deficient practice had the potential to result in double administration of medication to Resident 19 which could lead to liver and kidney damage.

Inspectors wroteBased on interview and record review, the facility failed to monitor for side effects for one of five sampled residents (Resident 67), who was on Cymbalta (medication used to treat depression [a mood disorder that causes a persistent feeling of sadness and loss of interest] and chronic pain). This deficient practice had the potential to result in undetected side effects, delay in physician notification of a change of condition, and a delay in providing necessary care and services to Resident 67.

Inspectors wroteBased on observation, interview, and record review, the facility failed to coordinate the initiation of RNA ([RNA] certified nursing aide program that helps residents to maintain their function and joint mobility) services with a resident's hospice (compassionate care for people who are near the end of life provided at the person's home or within a health care facility) provider after a resident exhibited documented limited range of motion [(ROM) full movement potential of a joint (where two bones meet)] for one out of five sampled residents. This failure resulted in unmet care needs and placed the resident at increased risk for functional decline.

Inspectors wroteBased on interview and record review, the facility failed to provide copies of medical records to one of four sampled residents (Resident 2) Responsible Party (RP 1) upon request. This deficient practice was a violation of RP 1's right to obtain a copy of Resident 2's medical records.

Inspectors wroteBased on interview and record review, the facility failed to timely report suspicions of abuse for one of four sampled residents (Resident 2). This deficient practice created a delay in the investigation of Resident 2's suspected abuse, and placed Resident 2 at risk for sustaining further abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure care plans were developed for two of four sampled residents (Resident 2 and Resident 3). This deficient practice placed Resident 2 and Resident 3 at risk of not receiving resident-centered care and interventions to assist them in reaching their highest practicable physical and psychosocial well-being.

Inspectors wroteFindings: 1. During a review of Resident 3's admission Record, the admission record indicated Resident 3 was originally admitted to the facility on [DATE] and was most recently re-admitted on [DATE]. Resident 3's admitting diagnoses included chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body) and hypotension (low blood pressure). During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool), dated 6/5/2025, the MDS indicated Resident 3 did not have cognitive impairments (a decline in one or more areas of mental function, such as memory, attention, or problem-solving). The MDS indicated Resident 3 was dependent on staff for toileting hygiene and rolling from left to right while in bed, requiring two-person assist. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 1, Registered Nurse (RN) 1, and the Social Services Director (SSD) implemented the facility's policy and procedure titled Abuse and Neglect Prevention Management, revised 2/2018, related to abuse reporting, for one of four sampled residents (Resident 2). This deficient practice resulted in LVN 1 and RN 1 not reporting suspicions of Resident 2's abuse on 6/13/2025, and the SSD not reporting suspicions of Resident 2's abuse on 6/26/2025.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician of a resident's continued episodes of orthostatic hypotension (OH- a condition in which your blood pressure quickly drops when you stand up after sitting or lying down) and failed to ensure physician involvement in the discontinuation of Physical and Occupational Therapy (PT, OT) services for one of two sampled residents (Resident 1), This failure resulted in a delay in appropriate medical intervention, placed the resident at risk for adverse outcomes including falls, syncope (dizziness), and compromised perfusion (pressure needed for blood to flow to blood vessels), and resulted in the premature termination of Medicare coverage.

Inspectors wroteBased on record review and interview, the facility failed to develop an individualized care plan for orthostatic hypotension (OH- a condition in which your blood pressure quickly drops when you stand up after sitting or lying down) for one of three sampled residents (Resident 1) when the facility failed to include clinically indicated instruction to administer Midodrine (an anti-hypotensive [low blood pressure] drug) prior to therapy sessions, despite the resident's history of symptomatic OH that affected participation in physical therapy. This failure placed Resident 1 at risk for falls, bodily injury, and early discontinuation of skilled therapy services.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident care plan was developed after brusing (a mark on skin, black and blue or red to purple form when blood pools under skin, caused by a blood vessel break) was noted for one resident out of three sampled residents (Residents 1). This deficient practice resulted in a delay in care and monitoring for Resident 1 and potentially negatively affected the delivery of care.

Inspectors wroteBased on interview and record review, the facility failed to ensure the following for one of three sampled residents (Resident 1): 1. Certified Nursing Assistant (CNA) 1 reported bruising (a mark on the skin, black and blue or red to purple form when blood pools under skin, caused by a blood vessel break) to Resident 1 ' s chest, left breast, flank, and left arm to the charge nurse or supervisor. 2. Treatment Nurse (TN) 1 documented the monitoring of Resident 1 ' s bruising. 3. TN 1 assessed Resident 1 ' s bruises. These deficient practices delayed Resident 1 ' s care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain respect and dignity for one of three sampled residents (Resident 1) when Certified Nursing Assistant (CNA) 1 failed to ensure Resident 1 was cleaned timely as requested. This failure resulted in Resident 1 expressing feelings of anger towards CNA 1 and had the potential for Resident 1 to exhibit feelings of hopelessness and long-term psychological distress.

Inspectors wroteBased on interview and record review, the facility failed to follow their Policy and Procedure (P&P), titled, Abuse and Neglect Prevention Management, for one out of three sampled residents (Resident 2) by failing to: 1. Ensure Registered Nurse (RN) 1 reported within 24 hours to the Administrator (ADM), the Director of Nursing Services (DON) and the California Department of Health (CDPH) when Resident 2 ' s family member (FM 1) alleged Certified Nursing Assistant (CNA) 2 was physically rough handling Resident 2. 2. Suspend CNA 2 after an allegation of rough handling was made by Resident 2. This resulted in a delay of an investigation by CDPH and had the potential for further abuse by CNA 2 to other residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of 10 sampled residents (Resident 3) who received dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) treatment received care in accordance with standards of practice, when the facility failed to: 1. Ensure nursing staff follow up on Resident 3 ' s potassium ([K] - a mineral the body needs, to help nerves and muscles work properly, especially your heart) lab order and notify the clinician of the abnormal results. 2. Ensure nursing staff ordered a potassium leverl instead of a Levetiracetam (Keppra - medications used to treat seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness] level as ordered by the clinician. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their Policy and Procedure (P&P), titled, Abuse and Neglect Prevention, when Certified Nursing Assistant (CNA) 2 did not report within two hours to the California Department of Public Health (CDPH), law enforcement, the ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities),the Administrator (ADM) and the Director of Nursing Services (DON) when Resident 1 informed CNA 2 that CNA 1 was rough with Resident 1 for one out of three sampled residents (Resident 1). This deficient practice resulted in a delay of an investigation by CDPH and had the potential for further abuse by CNA 1 to other residents within the facility while CNA 1 continued to work the remainder of CNA 1's scheduled shift.

Inspectors wroteBased on interview, and record review, the facility failed to follow their Policy and Procedure (P&P), titled, Abuse and Neglect Prevention, when the following occurred for one out of three sampled residents (Resident 1) by failing to: 1. Ensure a prompt investigation was initiated when Certified Nursing Assistant (CNA) 2 had knowledge Resident 1 alleged that CNA 1 was rough during care. 2. Ensure the facility implemented prompt measures to protect Resident 1 when CNA 2 had knowledge that Resident 1 alleged that CNA 1 was rough during care. These deficient practices resulted in the delay of a timely investigation and allowed for further potential abuse by CNA 1 to Resident 1 and other residents within the facility while CNA 1 continued to work the remainder of his scheduled shift.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Develop a person-centered care plan (document that helped nurses and other care team members organize aspects of resident care) and implement interventions (actions a nurse took to implement a care plan, intent to improve the resident's comfort and health) for one of four sampled residents (Resident 1), when the facility did not develop a care plan for Resident 1's non-compliance with the use of the call light (a button or device used in healthcare settings, typically located near a resident's bed, that allowed them to signal a nurse or caregiver when they needed assistance). This deficient practice had the potential to negatively affect Resident 1's physical, mental, and psychosocial well-being and had the potential to increase the resident ' s risk of falling.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) who required substantial/maximal assistance (staff does more than half the effort. Staff lifts or holds trunk or limbs and provides more than half the effort) with ADLs was provided water every two hours, according to physician order and care plan. This failure had the potential to cause dehydration and urinary tract infection ([UTI] an infection in the bladder/urinary tract) for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy to document the findings related to a change of condition (COC) every shift for two of three sampled residents (Resident 1 and Resident 2). This deficient practice had the potential to result in serious harm such as another episode of aggression towards others, and a delay of necessary treatments.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was free from significant medication error by administering amiodarone (a medication that prevents and treats irregular heartbeat) and metoprolol tartrate (medicine to treat high blood pressure) outside the parameters (specific instructions that you could measure) as ordered by the physician for one of three sample residents (Resident 2). These deficient practices had the potential to cause complications of hypotension (low blood pressure, dizziness and fainting leading to falls) and low pulse (leading to loss of consciousness).

Inspectors wroteBased on interview and record review, the facility failed to ensure infection prevention and control was maintained when the following occurred: 1. Resident 8 was not tested for Covid-19 (an acute disease caused by a coronavirus, capable of progressing to severe symptoms, including death, especially in older people and those with underlying health conditions) after symptoms of phlegm and a runny nose were first reported on 7/7/2024. 2. Certified Nursing Assistant (CNA) 1 worked two shifts, on 7/9/2024 and 7/10/2024, while experiencing Covid-19 symptoms. These deficient practices created the risk for avoidable spread of infection to all facility residents and staff and placed vulnerable facility residents at risk of suffering severe illness and/or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to answer the call light in a timely manner, ensure the resident's preference to shower by a certain time was honored, and ensure the call lights were not cancelled without asking the residents if they needed assistance for two residents out of two sampled residents (Resident 1 and Resident 2). These deficient practices had the potential to cause a negative impact on Resident 1's and Resident's ' 2s psychosocial well-being and caused a delay in care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services to maintain mobility (ability to move) for one of four sampled residents (Resident 53) with limited range of motion [(ROM) full movement potential of a joint (where two bones meet)] and mobility by failing to: 1. Monitor Resident 53's ROM in each joint of both arms and legs upon admission, quarterly, and annually in accordance with the facility's policies and procedures (P&P) titled, Resident Mobility and Range of Motion, which indicated the resident's comprehensive assessment will identify a resident's current range of motion of his or her joints. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]), Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function), and Speech Therapy ([ST or SLP] profession aimed in the prevention, assessment, and treatment of speech, language, communicative, and swallowing disorders) to one of four sampled residents (Resident 53), who had range of motion (ROM, full movement potential of a joint [where two bones meet]) mobility (ability to move) and swallowing problems. The facility failed to: 1. Provide Resident 53 with PT and OT evaluations upon admission to the facility in accordance with physician orders, dated 12/21/2022. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a Registered Nurse (RN) signed the Minimum Data Set (MDS, a resident standardized assessment and care-screening tool) assessments for four of 26 sampled residents (Resident 53, 61, 56, and 3) and failed to ensure the MDS assessment was complete prior to certification (action or process of providing someone or something with an official document attesting to a status of level of achievement) of completion. This deficient practice had the potential to affect the provision of care and provided inaccurate information upon submission to the Federal database.

Inspectors wroteBased on observation, interview, and record review, the facility failed to a develop care plans for 2 of 26 sampled residents (Resident 84 and 53) when: a. For Resident 84, the facility failed to develop a care plan for both 1/2 bedrails up to assist Resident 84 with repositioning and Resident 84's preference to have a female escort during outside clinic appointments. b. For Resident 53, the facility failed to develop a care plan for range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move) impairments, including the provision of Restorative Nursing Aide (RNA, certified nursing aide program that helps residents to maintain their function and joint mobility) services and activities of daily living (ADLs, tasks related to personal care including bathing, dressing, hygiene, eating, and mobility). [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to review, update and /or revised a care plan (a form that summarizes a person's health conditions and current treatments for their care) addressing fall, and the use of physical restraints for one of six sampled residents (Resident 32). These deficient practices had the potential to place Resident 32 at risk for recurrent falls, and to negatively affect the provision of care, and physical well-being of Resident 32.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide treatment and services for two out of three residents (Resident 35 and Resident 53) by failing to: a. Document Resident 53's hypoglycemic (low blood sugar) episode. This deficient practice had the potential to cause miscommunication of Resident 35's negative health trends and medication adjustments of insulin. b. [...]

Inspectors wroteDuring an observation, interview, and record review the facility failed to practice pressure related injury preventive practices for two out eight residents (Resident 3 and Resident 26) when the facility failed to: 1. Ensure a low air mattress (LAM) was set according to Resident 26's weight of 255 pounds and the LAM was set to 350 pounds. 2. Ensure the LAM was set according to Resident 3's weight of 161 pounds and LAM was set to 180 pounds. 3. Assess and prevent a pressure injury over Resident 3's ears. These deficient practices placed Resident 3 and Resident 26 at a higher risk of developing a pressure injury due to incorrect weight setting on the LAM and caused Resident 3 to develop a pressure injury on right ear due to prolonged use of medical device.

Inspectors wroteBased on observation, interview, and record review, the facility failed to date and input the time of continuous tube feeding administration, the date and time the tube feeding formula per policy and standards of care for three of five sampled residents (Resident 25, Resident 53, and Resident 61). This deficient practice had the potential to cause weight loss or infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure an informed consent was obtained for bed siderail use (a form of physical restraint) for five of five sample residents (Residents 13, 24, 27, 32 84). 2. Ensure Resident 27 had a physician's order for siderails prior to installing bed siderails. 3. Ensure Resident 13's responsible party (RP) was informed about the risk and benefits of bed siderail use. 4. Ensure Residents 84, 24, and 32 were evaluated for alternatives prior to installing bed rails. These deficient practices placed Residents 13, 24, 27, 32 and 84 at risk of inappropriate use of bedrails, placed the residents at risk for unnecessary restraints, and had the potential to violate the residents' rights and responsible party's right of being informed prior to restraint use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure four of four Restorative Nursing Aides (RNA, certified nursing aide program that helps residents to maintain their function and joint mobility) received an evaluation of competence (possession of sufficient knowledge or skill) as evidenced by: a. Four of four sampled residents (Resident 53, 3, 56, and 61) with range of motion [ROM, full movement potential of a joint (where two bones meet)] and mobility (ability to move) concerns did not receive ROM exercises to each joint of both arms and both legs in accordance with physician orders and the facility's job description titled, Restorative Nursing Assistant. b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the standardized recipes for the lunch menu was followed on 5/28/2024 when the following occurred: 1. Ten residents receiving a puree diet (foods that do not require chewing and are easily swallowed, all foods should be smooth and pureed to the consistency of pudding) received lasagna in a texture or form that met their needs. The pureed lasagna was lumpy, not smooth and had large pieces of pasta present requiring chewing before swallowing. 21 residents receiving a mechanical soft diet (provides foods that are easily chewed) received toasted garlic bread with a hard crust per the spreadsheet (food portion and serving guide) and menu. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and preparation practices when: 1. One staff working in the dish washing area did not wash their hands before removing the clean and sanitized dishes from the dish machine. 2. Expired food brought to residents from outside of the facility were stored in the resident food refrigerator. There was coffee from staff stored in the refrigerator. The refrigerator had no thermometer and monitoring system for the refrigerator temperatures. These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to food borne illness in 67 out of 74 residents who received food from the facility, including residents who had food stored in the resident refrigerator.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the clinical records were maintained in accordance with accepted professional standards and complete accurately the Advance Directives Acknowledgement ([ADA]- a form gives you the right to give instructions about your own health care) for three of six sampled residents (Residents 8, 63, and 53). These deficient practices resulted in inaccurate, and incomplete medical records, and had the potential to result in uncertainty in the care and services for residents and placed residents at risk of not receiving care based on their wishes due to inaccurate and incomplete documentation for Residents 8, 63, and 53.

Inspectors wroteBased on observation, interview, and record review, the facility Quality Assurance and Performance Improvement (QAPI - a systematic, interdisciplinary, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes while involving residents, families, and nursing home caregivers) committee failed to identify, develop, and implement action plans to ensure: 1. Range of motion (ROM- full movement potential of a joint where two bones meet) was monitored for all residents. (see F-Tag F688) 2. Informed consent for psychotropic medications (drug that affects how the brain works and causes changes in mood) including behavior monitoring and signature verification was done for all residents. (see F-Tag 758) 3. Informed consents were obtained for bed rails. (see F-Tag 700) 4. Physical therapy services were provided per physician's orders. (see F-Tag 825) 5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure standard infection control practices were followed for seven of by failing to: 1. Ensure Resident 22 and Resident 24's oxygen nasal cannula tubing (a device used to deliver supplemental oxygen placed directly in a resident's nostrils) was dated, properly stored when not in use, and was off the floor, and ensure Resident 69's nebulizer (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) mask was dated, labeled, properly stored when not in use, and was not touching the floor. 2. Ensure the Social Services Director (DSD) and Registered Nurse (RN) 1 removed their gloves when moving between Resident 33 and Resident 274, and Resident 17 and Resident 13. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess the need for modifications to the call light system for one out of eight (8) residents, (Resident 27) by failing to: 1. Ensure the facility the call light for Resident 27 working properly and alarmed when activated by Resident 27. 2. Ensure the Certified Nursing Assistant (CNA 1) reported Resident 27's call light needed repair and was not working to the Maintenance Supervisor (MS). These deficient practices resulted in a delay in obtaining necessary care and services and placed Resident 27 at risk for an accident if called for help.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain informed consent prior to the administration of psychotropics (medications that affect the mind, emotions, and behavior) for three out of five residents (Resident 31 and 32). This deficient practice placed Residents 31 and 32 at risk for avoidable harm from unwanted adverse effects (a harmful and undesired effect resulting from a medication or intervention) related to psychotropic medication use and removed the residents' rights to make decisions about the care and treatments they received in the facility.

Inspectors wroteBased on interview and record review, the facility failed to honor a resident's preference to have a female staff member escort the resident to clinic visits outside of the facility for one of one sampled resident (Resident 84's). This deficient practice caused Resident 84 to repeatedly be accompanied to appointments by a male staff member despite Resident 84's wishes to have a female escort. This failure also had the potential to cause unnecessary psychological harm to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the primary physician of the change in condition of decline in range of motion (ROM, full movement potential of a joint [where two bones meet]) in both ankles for one of four sampled residents (Resident 53), who had limited mobility (ability to move) concerns. This deficient practice resulted in Resident 53's development of contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to joint stiffness) to both ankles. Cross reference F688 and F726.

Inspectors wroteBased on observation, interview and record review, the facility staff failed to ensure one of six sampled residents (Resident 32) was free from an unnecessary physical restraint, as evidenced by: 1. Failing to ensure appropriate assessment for less restrictive measures prior to using a physical restraint for Residents 32. 2. Failing to obtain a physician order for the use of bed against the wall used as a physical restraint for Resident 32. 3. Failing to obtain a consent form for the use of a physical restraint, and of side rails for Resident 32. These deficient practices placed Resident 32 at risk for entrapment (when a person is trapped by the bed rail in a position they cannot move from) and had the potential to cause psychosocial harm from not being treated with dignity and respect.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the Preadmission Screening and Resident Review ([PASRR] resident screening prior to admission, to determine if the person has, or is suspected of having, a mental illness) Level I screen was completed accurately for one of one resident, (Resident 22). This deficient practice had the potential for Resident 22 to not receive the necessary and appropriate behavioral treatment and services and placed Resident 22 at risk for further complications of schizophrenia (mental illness that effects how person thinks, feels, and behaves) and major depressive disorder (a mental health condition that causes loss of interest in activities of daily living).

Inspectors wroteDuring an observation, interview, and record review the facility failed to ensure the staff provided the necessary care and services to one out of eight sampled residents (Resident 27) that promoted residents well-being by failing to: 1. Ensure Certified Nursing Assistant (CNA 1) offered assistance to Resident 27, to clean up his bed that had a large amount of feces (stool). 2. Ensure CNA 1 gave Resident 27 had ice water when requested. 3. Ensure Resident 27 had a working call light to communicate his needs to staff. These deficient practices had the potential to have a negative impact on Resident 27's quality of life and caused Resident 27 needs not to be met like toileting, bathing receiving drinking water.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment and services to maintain or improve the ability to perform activities of daily living (ADLs, tasks related to personal care including bathing, dressing, hygiene, eating, and mobility) for one of four sampled residents (Resident 53) with limited range of motion [(ROM) full movement potential of a joint (where two bones meet)] and mobility by failing to transfer Resident 53 out of the bed daily. This deficient practice resulted in Resident 53, who had a history of depression, to experience limited social interaction and a decline in ROM, mobility, ADLs, affecting Resident 53's quality of life. Cross reference F656, F688, and F825.

Inspectors wroteBased on observation, interview, and record review the facility failed to monitor behaviors and provide non-pharmacological behavioral interventions for antipsychotic medication (a type of psychotropic psychiatric medication used to treat psychotic disorders) use for one out of five residents (Resident 61). This deficient practice had the potential to cause Resident 61 extrapyramidal side effects (a series of potentially irreversible psychiatric drug induced movement disorders) and potentially prevent Resident 61 from functioning at her highest practicable physical, mental, and psychosocial well being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from medication error rates below 5% for one out of five residents (Resident 61). This deficient practice had the potential for residents to be at risk for medication errors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a therapeutic mechanical soft (texture-modified [moist and soft] foods for people who have difficulty chewing and swallowing) diet was served as prescribed by the physician for one of two sampled residents (Resident 42). This deficient practice had the potential to cause Resident 84 to choke on food that was too difficult to chew or swallow.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control measures by failing to: 1. Ensure a COVID-19 (Coronavirus, a highly contagious respiratory illness caused by a virus that can easily spread from person to person) outbreak was reported to the proper California Department of Public Health (CDPH) District Office. 2. Ensure staff was performing proper hand hygiene when going from one resident room to another resident room. This deficient practice had the potential to result in the spread of Coronavirus to residents and staff that could cause respiratory illness, hospitalization, and death.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive and resident-centered care plan to address the risk of exposure to COVID-19 (a highly contagious respiratory illness caused by a virus that can easily spread from person to person) for two of four sampled residents (Residents 1 and Resident 2). This deficient practice had the potential to negatively affect the delivery of nursing care and medical interventions to Residents 1 and 2.

Inspectors wroteBased on interview and record review, the staff failed to ensure the admission agreement (contract) was reviewed, completed and signed by the resident or responsible party, for 1 of 3 residents (Resident 1), at the time of admission according to the facility's admission policy. This deficient practice resulted in Resident 1 not being informed of his rights, financial responsibilities, Medicare or Medicaid benefit, and had the potential that concerns about admissions were not addressed. Findings A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on [DATE], with a diagnosis that included malignant neoplasm of kidney and renal pelvis (cancer in the kidney and the urinary tube), type 2 diabetes (DM-high blood sugar), and hypertension (HTN-high blood pressure). [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a copy of the personal belonging inventory list to 1 of 3 residents, Resident 1, on admission. This deficient practice had the potential that Resident 1 won't be able to monitor his belongings and were placed at risk to go missing, misplaced, or stolen. Findings A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on [DATE], with diagnosis that included malignant neoplasm of kidney and renal pelvis (cancer in the kidney and the urinary tube), type 2 diabetes (DM-high blood sugar), and hypertension (HTN-high blood pressure). A review of Resident 1's history and physical (H&P) dated 7/19/2023, the H&P indicated Resident 1 had the capacity to understand and make medical decisions. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe food preparation practices in the kitchen when: A. The Ice machine's internal compartments were dirty as evidenced by a black substance on the surfaces. B. Dietary Staff such as cook and assistant cook wearing jewelry (bracelet and dangling earrings) during food preparation. These failures had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness in 72 out of 79 medically compromised residents who received food and ice from the kitchen.

Inspectors wroteBased on observation, interview, and record review, facility failed to ensure an accurate assessment was conducted for three of three sampled residents (Residents 124, 58 and 49). Residents 124, 58, and 49 did not have an accurate assessment for following: 1. Failure to address Resident 124's complaints of pain. 2. Failure to accurately assess and monitor Resident 58's skin integrity, who was at a very high risk for skin breakdown due to the application of an orthopedic brace (a medical devices designed to address musculoskeletal issues; they are used to properly align, correct the position, support, stabilize, and protect certain parts of the body as they heal from injury or trauma) to the right leg. 3. Failure to ensure Resident 49's bowel and bladder assessment was conducted timely. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of eight sampled residents (Residents 123 and 58) fingernails and moustache/beard were clean and trimmed regularly. This deficient practice had the potential to negatively impact Resident 123 and 58's quality of life and self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of eight sampled residents (Resident 58), who was readmitted to the facility with intact skin integrity and an order for an orthopedic brace (medical device designed to address musculoskeletal issues; used to properly align, correct the position, support, stabilize, and protect certain parts of the body as they heal from injury or trauma) to the right leg, received care consistent with professional standards of practice, to prevent medical-device related pressure ulcers (injuries result from use of medical devices, equipment, furniture, and everyday objects in direct contact with skin and because of increased external mechanical load leading to soft tissue damage) and received necessary treatment and services to promote healing, prevent infection and prevent new pressure ulcers from developing. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 16 sampled residents (Residents 1 and 5), who had limited range of motion ([ROM] the extent of movement of a joint) and limited mobility, received appropriate treatment and services to increase ROM, prevent further decrease in ROM, and maintain or improve mobility. This deficient practice had the potential to place Residents 1 and 5 at increased risk for further decline and development of contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the bed siderails were not loose for five of five sampled Residents (Residents 174, 6, 13, 1, and 49). This deficient practice placed Residents 174, 6, 13, 1, and 49 at risk for accidents and hazards such as having a body part caught between the rails, and/or falls.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure dietary staff were able to identify and produce the correct textures for pureed diets (food textures made of liquidized or crushed fruit or vegetables for people who cannot chew or have a problem swallowing). The dietary staff did not prepare the appropriate texture of meat according to the Dietary Services Supervisor (DSS). This deficient practice had the potential to result in choking or aspiration (when swallowed food goes down the airway, cutting off breathing) during lunch time for 12 out of 12 residents on a pureed diet. This deficient practice had the potential to result in choking or aspiration (when swallowed food goes down the airway, cutting off breathing) during lunch time for 12 out of 12 residents on a pureed diet.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 12 of 12 residents receiving a pureed diet (food texture made of liquidized or crushed fruit or vegetables for those who do not need to chew or have problem swallowing) received a lump-free meal. This deficient practice had the potential to result in increased choking risk for the residents receiving a pureed diet.

Inspectors wroteBased on observations, interview, and record review the facility failed to maintain Resident beds side rails (structural support attached to the frame of a bed, intended to prevent falls and assist in repositioning and getting out of bed). in a safe operating condition for 5 of 5 sampled Residents. (Resident 174, 6,13,1, and 49) These deficient practices placed the residents at risk for a potential accident or entrapment (when a resident becomes caught between the mattress, bed or headboard and the bed rail, or between the rails) related to lose and faulty screws on side rails.

Inspectors wroteBased on observation, interview, and record review the facility failed to: a. ensure two out of 8 sampled Residents (Residents 29 and 3) were treated with respect to promote dignity by failing to serve Residents 29 and 3 meals at the same time as their roommates. b.respond to residents' needs and requests for assistance with toileting and activities of daily living (ADL) in a timely manner for three of 12 sampled residents (Resident 22, 123, and 124). These deficient practices has the potential to cause psychosocial harm or decline to the residents and violates residents' right to be treated with dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose properly of the resident's medical records on the tube feeding bag (nutritional supplements) for one of five sampled residents (Resident 20). This failure has the potential outcome of residents' personal medical information being released to the public without the resident's knowledge or consent.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one out of one resident (Resident 16) was free from physical restraint when bed/chair alarm (pressure sensing devices that alarm when the resident gets up) order was not obtained from physician prior to applying. This deficient practice had the potential to inhibit Resident 16's freedom of movement or activity which had a potential for physical and psychosocial decline.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set ([MDS] a comprehensive standardized assessment and care-screening tool) for a significant change in status was completed within the required time frame for one of eight sampled resident (Resident 58). This deficient practice had the potential to negatively affect the provision of necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to effectively manage the pain for one of one sampled resident (Resident 13) experiencing pain. This deficient practice had the potential to negatively affect Resident 13's physical comfort and psychosocial well-being and had the potential to increase the pain level and result in an unmanageable pain level.

Inspectors wroteBased on observation, interview, and record review, staff failed to provide reasonable accommodation to meet the resident's needs by failing to ensure the resident's call lights was within reach for three of eight sampled residents (Residents 123 and 124). This deficient practice had the potential to negatively impact Resident 123, and 124's psychosocial well-being or result in delayed provision of services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one controlled substance (medication with a high potential for abuse) was disposed of, after expiration and discontinuation of the physician's order for one out of one resident (Resident 9). This deficient practice increased the facility's risk for potential loss, diversion (transfer of a medication from a legal to an illegal use) or accidental exposure to controlled substances, and potential for harm to residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure it was free of medication error rate of less than five (5) percent (%) for two of six randomly selected residents (Resident 48 and 35) observed during medication administration. This deficient practice of two medication errors out of 30 opportunities (observations during medication administration), resulted in a medication administration error rate of 6.67 %, that exceeded the five (5) percent threshold and the potential to increase the side effects of the medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were followed by Licensed Vocational (LVN 1) during care for one out of seven residents (Resident 124) who resided in a yellow zone room (area for newly admitted or readmitted residents, residents with incomplete or unknown COVID-19 [a highly contagious infection, caused by a corona virus that can easily spread from person to person] vaccination status). This deficient practice had the potential to place the residents, staff, and the community at risk for the spread of infection.