Health Care Ctr at the Forum at Rancho San Antonio

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's legal representative (LR) who was Resident 1's son ( LR, is an individual authorized under state law to act on behalf of a resident in a facility, such as a nursing home or assisted living. They manage affairs, make decisions, or access information. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents were informed of their rights upon admission, when the admission Agreement for Skilled Nursing Facilities was not completed for one of three residents (Resident 1 affected). This deficient practice resulted in the resident not being informed of his rights.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure food was stored and equipment was maintained in accordance with professional standards for food safety when undated food items, food past their discard by date, uncovered food, rotten vegetables, and old, chipped, worn-out equipment were found in the kitchen. These failures had the potential to cause the growth of micro-organisms which could cause foodborne illness and cross-contaminated food for the 44 residents eating at the facility, with one resident on tube feeding and still eating lunch.

Inspectors wroteBased on interview and record review, the facility failed to ensure three of 14 residents (Resident 51, 17 and 59) had been informed about having an advance directive (AD, legal form directing their wishes about their healthcare, whether from them or a named individual on their behalf), when no documentation was found about AD and the Physician Orders for Life-Sustaining Treatment (POLST, a legal document stating the kind of medical treatment residents want toward the end of their lives) were not completed and not readily available in the event of a medical emergency. This failure had the potential to result in inability to make medical decisions and could lead to the delivery of unnecessary or inappropriate medical services.

Inspectors wroteBased on interview and record review, the facility failed to ensure 3 out of 5 sampled residents (Residents 1, 35, and 51) were free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behavior) when:1. Resident 1 received trazodone (an antidepressant) for insomnia without side effect monitoring and without adequate monitoring when staff did not monitor the quantity (hours) of sleep to evaluate whether the medication was effective for her insomnia.2. Resident 35 received trazodone for insomnia without adequate monitoring for hours of sleep.3. Resident 51's as-needed (PRN) order for trazodone did not have a 14-day end date, as required. The failures resulted in inadequate and ineffective monitoring for side effects and effectiveness of psychotropic medications.1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the comprehensive care plan with measurable objectives, goals, and interventions, was developed and implemented for 4 out of 14 sampled residents (Residents 1, 3, 38, and 52), when:1. Resident 1 did not have care plans for migraine and insomnia;2. Resident 38 did not have a care plan related to use of apixaban (Eliquis, an anticoagulant - or blood thinner- to prevent blood clots) and osteoporosis (a bone disease causing weak, brittle bones due to decreased bone mass). 3. Resident 3 did not have a care plan developed for pressure ulcer; and4. Resident 52 did not have a care plan for the use of urinary catheter (flexible tube inserted into the bladder to drain urine). This failure placed the residents at risk of not being provided appropriate, consistent, and individualized care for their medical conditions. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to manage pain for one of 5 residents (29) when license nurses did not administer pain medication to Resident 29 according to the pain level ordered by the physician. This failure had the potential for the residents to experience avoidable pain and could negatively affect their quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure controlled medications (those with a high abuse potential) records were complete and fully accounted when:1. Drug disposition records conducted on [DATE] did not have a registered nurse's (RN's) signature to show the controlled medications were disposed of (destroyed) by a pharmacist and an RN, as required.2. Controlled medication use audit for three out of five sampled residents (Residents 1, 56, and 58) did not reconcile. The residents' controlled medications were signed out of the Controlled Drugs Records (CDR, inventory record of controlled drugs) but not documented on the Medication Administration Record (MAR, record of medications administered to a resident) to indicate they were administered to the residents. [...]

Inspectors wroteBased on interview and record review, the facility and the Consultant Pharmacist (CP) failed to ensure the pharmacist's medication regimen review (MRR) recommendations were acted upon/responded to on a timely basis. The CP's recommendations from November 2025 through January 2026 were delayed, resulting untimely response for 4 out of 14 sampled residents (Residents 1, 10, 29, and 38). For Resident 10, CP's recommendation for a dose change of aspirin was not acted on timely. For Resident 1, the recommendation for trazodone (an antidepressant) side effect monitoring was not acted on and carried out timely. For resident 38, the anticoagulant (a blood thinner to prevent blood clot) dose change recommendation was not acted on and carried out timely. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure 2 out of 14 sampled residents (Residents 7 and 38) were free from unnecessary medications when:1. Resident 38 received apixaban (Eliquis, an anticoagulant - or blood thinner- to prevent blood clots) at a dose higher than manufacturer's recommendation for her diagnosis, age, and weight without the risk/benefit assessment from the physician. This had the potential for the resident to suffer from adverse effects (such as bruising, bleeding) from anticoagulant use.2. The nursing staff did not monitor for signs and symptoms of related to apixaban use for Resident 38. This had the potential for untimely recognition and interventions for adverse effects from anticoagulant use.3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food served to the residents were at acceptable temperature. This failure had the potential to impact on the residents' nutritional status and not meet the residents' desires.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper infection prevention techniques were followed when:1. The Licensed Vocational Nurse (LVN) A failed to wear Personal Protective Equipment (PPE, equipment worn to minimize exposure to hazards that cause serious workplace injuries and illness) when he entered the room of a Covid-19 (highly contagious respiratory illness caused by the SARS-CoV-2 virus) positive resident (Resident 51);2. The Registered Nurse (RN) B failed to change gloves during tube feeding (liquid nutrients given through a tube inserted in the stomach) for Resident 2;3. Licensed Vocational Nurse (LVN) C used the same tissue to wipe excess liquid from both eyes during the administration of three different eye medications for Resident 4; and4. [...]

Inspectors wroteBased on observation, interview, and policy review, the facility failed to treat one of 14 residents (23) with respect and dignity when certified nursing assistant D (CNA D) was standing while feeding Resident 23 in his room. This failure had the potential to cause Resident 23 feeling low self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to revise and implement comprehensive care plan that included measurable objectives and interventions for one out of 14 sampled residents (Resident 33) when Resident 33's foley catheter (a device inserted into the bladder [organ that collects urine] to drain urine, made of a semi-flexible plastic tube) care plan was not revised or updated after the intervention failed. The failure had the potential for Resident 33 not attaining the highest practicable physical, mental, and psychosocial well-being. During a review of Resident 33's clinical record indicated Resident 33 was admitted to the facility on [DATE] with diagnosis including urinary retention. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure necessary care and services were provided to one of three residents (41) when Resident 41's pacemaker (a small battery-operated device that helps the heart beats in a regular rhythm) information was not in his medical records. This failure had the potential for not preventing Resident 41 from experiencing serious health conditions.

Inspectors wroteBased on interview and record review, the facility failed to assess fall risk for one of three residents (36) when Resident 36 had not had quarterly fall risk assessment since after 5/28/25. This failure had the potential to result in Resident 36's fall risk and fall intervention were not up to date to prevent her from falling and getting injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the proper use of bed rails (side rails, adjustable rigid bars attached to the side of a bed) for one of nine residents (Resident 2) with side rails when there was no documented evidence that the bed rail entrapment risk assessment was completed. This failure had the potential to place the residents at risk of entrapment and serious injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for one of three sample residents (Resident 1) when: 1. The facility scheduled a change in medication administration time to start on 7/17/24 when it should have started on 7/18/24; and, 2. A medication was documented as administered when it should have been documented as refused. These failures had the potential to compromise the resident's health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure 5 of 11 resident (Residents 3, 13, 24, 334, and 336) had: 1. documentation of reviewing advance directive status, when there was no documentation of a staff member discussing the status with four of the residents or residents' representative, or 2. the POLST (Physician Orders for Life Sustaining Treatment) for three residents, were not filled in accurately, when Section D had no check marks for the advance directive status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper storage of medications in medication room when the following were found: 1. An expired over the counter (OTC: medications can buy without written by medical doctor) medications; 2. An expired suppositories (supp: solid, small, and cone shaped medications that melts upon insertion into the body). These failures had the potential for residents to receive medications with reduced efficacy (effectiveness).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food safety when: 1. Bowls used for food preparation and food service were stacked and stored wet; 2. There were undated and outdated food items in the facility's kitchen freezer; These failures had the potential to cause food contamination and food-borne illness to 38 of 39 residents who received their food from the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infection control practices were implemented when: 1. Foley catheter ((F/C: a semi-flexible plastic tube, one end inserted into bladder (a body organ that stores urine] and the other end attached to a bag that collects urine)'s tubing (hard plastic tube attached between F/C and F/C's drain bag [urine collection bag] to drain urine from body) laying on floor for Resident 332; 2. Nasal Cannula (NC: a medical device to provide supplemental oxygen [O2: colorless, odorless, and tasteless gas supports life] to residents) tubes on floor and unchanged for Resident 334; 3. Licensed nurse failed to do hand hygiene after removing gloves; and 4. Phlebotomist (PHMT: person responsible to take samples of blood from residents for testing) was in the hallway with gloves on. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure to treat with dignity and privacy for 1 of 2 sampled Resident (Resident 332) when: 1. Resident 332's foley catheter (F/C: a semi-flexible plastic tube, one end inserted into bladder [ a body organ that stores urine] and the other end attached to a bag that collects urine) drain bag (collects urine that drains through the F/C) was left uncovered. These failure had the potential for adverse effects on the psychosocial well-being and health of Resident 332.

Inspectors wroteBased on interview and record review, the facility failed to give notice of ending of Medicare Part A stay or therapies under Part B within a timely manner to one of three randomly selected residents (Resident 26). This failure had the potential for Resident 26 not being able to appeal for continued payment by Medicare.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, an assessment tool) was accurate for one of 14 sampled residents (Resident 19). For Resident 19, the assessment of his alarm device was inaccurate and the MDS did not reflect the presence of a wanderguard (a device that activates an alarm when a resident attempts to leave a safe area.) Failure to accurately assess Resident 19's use of a wanderguard had the potential to compromise the facility's ability to develop and implement resident-centered care plans and interventions.

Inspectors wroteBased on observation, interview and record review the facility failed to implement their elopement risk care plan (a written document which communicates and directs the care and services, including goals and interventions required to meet a resident's individualized need) for one of 14 sampled residents (Resident 19). This failure had the potential for Resident 19's attempts at elopement to go undetected and jeopardize Resident 19's safety.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow their policy and procedure (P&P) for medication order for one of five sampled resident (Resident 340) when; 1. Resident 340 received medication pantoprazole sodium delayed release (used to reduce amount of acid in stomach to release the active ingredient (s) later after taking it) after breakfast. This failure had the potential to affect the health and well-being of Resident 340.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow physician's orders to administer oxygen (O2: colorless, odorless, and tasteless gas supports life) for 1 of 2 sampled resident (Resident 24). This failure had the potential to compromise Resident 24's health, and well-being.

Inspectors wroteBased on interview and record review, the facility failed to determine if bed rails were appropriate for two of 39 resident (Residents 17 and 81) prior to installing them. This failure had the potential of the residents being harmed from improper bed rail use.

Inspectors wroteBased on observation and interview, the facility failed to post the nurse staffing hours in a prominent place. This failure did not follow the federal regulation of posting them in a prominent place readily accessible to residents and visitors.

Inspectors wroteBased on interview, and record review, the facility failed to ensure 1 of 2 sampled resident (Resident 339) was free from unnecessary psychotropic medication (drug that affects brain activities associated with mental processes and behaviors) when; 1. No target behavior monitoring for use of medication quetiapine (antipsychotic medication used to treat certain mental/mood disorders); 2. No non-pharmacological (any type of healthcare interventions without use of medications) approaches to minimize the need to use for medication quetiapine; 3. Pharmacy consultant (expertise in managing medications and providing clinical guidance on safe and appropriate medication use for residents)'s recommendations for quetiapine had not been followed up and; 4. MD (medical doctor)'s response for pharmacy recommendations had not been followed up. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications and biologicals were stored and labeled appropriately when: 1. Two unlabeled and opened bottles of Di-Dak-Sol diluted Dakin's solution (used to treat or prevent infections caused by cuts or abrasions, skin ulcers, pressure ulcers, diabetic foot ulcers, or surgery), and one unlabeled opened hydrocortisone cream 1% -topical (used to help relieve redness, itching, swelling, or other discomfort caused by skin conditions) were found in the treatment cart; 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food safety when: 1. A scoop was inside the dry legume container in the dry storage area; 2. There were opened, undated, unlabeled, and outdated food items in the food preparation and dry storage areas; 3. There were opened, undated, and unlabeled food items in the walk-in refrigerator; 4. There were undated, and unlabeled food items in the walk-in freezer. These failures had the potential to cause food contamination and food-borne illness to 22 of 22 residents who received their food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff implemented proper infection control practices when: 1. The licensed nurse did not change gloves between tasks; 2. Registered Nurse D (RN D) did not perform hand hygiene in between procedures; 3. Resident 127's spirometer (an apparatus for measuring the volume of air inspired and expired by the lungs- measures ventilation, the movement of air into and out of the lungs) mouthpiece was touching the side table; 4. Trash can attached to the Medication Cart B has used facial mask and N-95; 5. Three medication containers inside the medication room refrigerator has grayish substance, and disposal container for discontinued and refused medication had red spots of liquid substance inside the medication room; 6. There was a grayish powder seen in the first drawer of the treatment cart. 7. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services were provided to meet the professional standard of practice for one of four residents (Resident 6) who had a pacemaker (implanted device for a heart condition, a battery-powered device implanted inside the heart to restore a normal heartbeat) when: 1. The resident's medical record had no pacemaker-paced rate information, 2. The licensed nurse did not develop a care plan to manage pacemaker care. These failures had the potential to compromise Resident 6's health and safety.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 12 sampled residents (Resident 17) was free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behaviors) when Resident 17 received Lorazepam (anxiolytic medication, used to reduce anxity)without a stop date. The failure had the potential to result in inadequate use of psychotropic medications.