Healthcare Center of Orange County

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the bed hold policy was carried out for one of four sampled residents (Resident 3). * The facility failed to ensure Resident 3's previously assigned room and bed were provided when the resident returned to the facility from the acute care facility, during the seven-day bed hold period. This failure had the potential for the resident to have an inappropriate discharge.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of four sampled residents were provided the necessary care and services to maintain their highest practicable well-being. * The facility failed to ensure Resident 1 was provided an escort to an outpatient appointment as instructed by the staff from physician's office. This failure had the potential to delay resident's care.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of four sampled residents were provided with dietary preferences. * The facility failed to ensure Resident 1's documented allergy to lactose was carried out. This failure had the potential for the resident to have an intolerance or allergic reaction to food.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to implement the care plan intervention for fall prevention for one of three sampled residents (Resident 3) reviewed for falls. * The facility failed to ensure Resident 3 was provided with a yellow wristband as per the resident's care plan intervention for fall. This failure had the potential to affect the facility staff's ability to provide appropriate supervision and implement timely fall prevention measures.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure one of six sampled residents (Resident 3) received the appropriate care and services for pressure injury prevention. * The facility failed to offload Resident 3's bilateral heels per the physician's orders. This failure had the potential to place Resident 3 at risk to develop pressure injury on her heels.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the appropriate care and services to prevent UTIs for one of one of six sampled residents (Resident 4) with an indwelling urinary catheter (a flexible, sterile tube which drains the urine from the bladder into a bag outside of the body). * The facility failed to ensure Resident 4's indwelling urinary catheter drainage bag was not touching the floor. This failure posed the risk for Resident 4 to develop UTIs and complications from UTIs.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of one sampled resident (Resident 3) reviewed for side rail use was free from accident hazards related to the use of side rails. * The facility failed to ensure Resident 3's use of side rails as per the resident's plan of care for fall prevention were indicated in Resident 3's bed rail assessment. This failure had the potential to place Resident 3 at risk for entrapment and serious injury from the side rail use.

Inspectors wroteBased on interview and closed medical record review, the facility failed to ensure the medical record was accurately maintained for one of three sampled residents (Resident 1). * The facility documented Resident 1's family member was called to schedule a care plan meeting on 12/14/25, however, Resident 1 was transferred to the acute care hospital on [DATE]. This failure had the potential for the resident's care needs not being met as the medical record was inaccurate.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services to ensure one of three sampled residents (Resident 1) was free from accident hazards. * Resident 1 had an unwitnessed fall incident on 9/18/25. The facility failed to investigate Resident 1's family member's grievance regarding Resident 1's position near the edge of the bed on 9/16/25. Resident 1's fall risk assessment was inaccurate resulting in an incorrect fall risk score status. In addition, the facility failed to update Resident 1's care plan addressing the resident's risk for fall and his behavior of dangling his legs off the bed prior to his fall incident. [...]

Inspectors wroteBased on interview and medical record review, the facility failed to provide the necessary care and services to maintain the highest practicable well-being for one of three sampled residents (Resident 1). * LVN 1 delayed contacting emergency services after Resident 1 who was on an anticoagulant, had an unwitnessed fall and injury to his forehead. This failure had the potential to negatively affect the resident's well-being as the necessary care and services were not provided.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the pharmaceutical services were provided to meet the residents needs for two of three sampled residents (Residents 1 and 2). * The facility failed to administer Resident 1's medications scheduled. In addition, the facility documented Resident 1's medications were administered on 9/19/25 at 1700, 1800, 1900, and 2100 hours, after the resident was transferred to the acute care hospital. * The facility failed to administer Resident 2's medications scheduled on 9/15 and 9/22/25 at 2100 hours. These failures had the potential to negatively affect the residents health conditions and posed the risk for diversion of the medications.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive person-centered care plan was revised for one of three sampled residents (Resident 2). * The facility failed to revise Resident 2's care plan when Resident 2 had a fall. This failure placed the resident at risk of not being provided appropriate, consistent, and individualized care.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the residents' medical record were complete and accurate for two of three sampled residents (Residents 2 and 3). * Resident 2's fall risk assessments were incomplete. * Resident 3's fall risk assessments were incomplete. These failures posed the risk for the residents care needs not being met as their medical record information were inaccurate and incompleteFindings: Review of the facility's P&P titled Charting and Documentation revised 7/2017 showed documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. 1. Medical record review for Resident 2 was initiated on 10/1/25. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's Fall Risk Evaluation dated 6/19/25, showed blank entries for the following sections: [...]

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the individualized and ongoing activity program to meet the needs and interests for three of three sampled residents (Residents 1, 2, and 3) reviewed for activities. This failure had the potential for Residents 1, 2, and 3 to negatively impact the residents' well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure adequate respiratory services. * The facility failed to ensure an adequate number of portable oxygen tanks were kept on site for use in an emergency for the residents with a physician's order for continuous supplemental oxygen therapy for 51 of 52 residents who resided in the subacute unit and four of 41 residents who resided in skilled nursing unit. * The facility's total number of portable oxygen tanks consisted of 46 tanks (43 E tanks and three H tanks). However, a total of 55 residents in the facility had a physician's order for a continuous supplemental oxygen. [...]

Inspectors wroteBased on interview and facility document review, the facility failed to determine the number of portable oxygen tanks needed to conduct an emergency evacuation of residents who required continuous supplemental oxygen therapy for 51 of 52 residents who resided in the subacute unit and four of 41 residents who resided in skilled nursing unit. * The total number of residents residing in the facility (subacute unit and skilled nursing unit) who had an active physician's order for continuous supplemental oxygen was 55. However, the facility had a total inventory of 46 full oxygen tanks on site. This posed the risk for negative health outcomes for the residents in the event of an emergent evacuation from the facility.

Inspectors wroteBased on interview, facility document review, and facility P&P review, the facility failed to respond to the concerns brought up by the residents during the Resident Council meetings on 3/19 and 5/5/25, regarding the call lights not being answered in a timely manner. This failure had the potential for the residents' identified issue to not be resolved and a decline in quality of care for the residents.

Inspectors wroteBased on observation and interview, the facility failed to maintain a homelike environment for one sampled resident (Resident 15). * Resident 15 resided in Room A. Resident 15 was observed sitting on her bed eating lunch. A pest was observed floating on the surface of Resident 15's milk. This failure had the potential to negatively impact the resident's quality of life.

Inspectors wrote2. Medical record review for Resident 15 was initiated on 6/2/25. Resident 15 was admitted to the facility on [DATE]. Review of Resident 15's H&P examination dated 5/11/25, showed Resident 15 had the capacity to understand and make decisions. Review of Resident 15's Order Summary Report dated 6/2/25, showed the following physician's orders: - dated 5/9/25, to administer aripiprazole oral tablet 5 mg, one tablet by mouth in the morning for bipolar disorder manifested by angry outbursts; and - dated 5/9/25, to administer trazodone oral tablet 50 mg, one tablet by mouth at bedtime for depression manifested by inability to sleep. - dated 5/11/25, for the use of the aripiprazole medication, to monitor for bipolar disorder manifested by angry outburst every day and night shift; [...]

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility to failed to ensure the discharge instructions were documented for one of three sampled residents reviewed for closed records (Resident 100). This failure had the potential for Resident 100 to have an inappropriate discharge.

Inspectors wroteBased on interview and medical record review, the facility failed to coordinate an assessment with the PASARR program for one of two final sampled residents (Resident 15) reviewed for PASARR when the resident had an updated diagnosis of depression, schizoaffective disorder, bipolar disorder, and anxiety disorder. This failure posed the risk for Resident 15 not receiving the necessary specialized services specific to treat mental illness.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the comprehensive care plan was implemented for one of 22 final sampled residents (Resident 63). * The facility failed to implement the comprehensive plan for contact isolation precautions for Clostridium difficile, for Resident 63. This failure placed the resident at risk for not being provided appropriate, consistent, and individualized care.

Inspectors wrote* The facility failed to ensure RNA services were provided as ordered by the physician for Resident 10. 4. On 6/2/25 at 1115 hours, Resident 10 was observed lying on his bed. Resident 10's left arm was observed in a flexed position. Medical record review for Resident 10 was initiated on 6/2/25. Resident 10 was admitted to the facility on [DATE]. Review of the Resident 10's Order Listing Report, showed the following physician's order dated 2/21/25: - for RNA for PROM (passive range of motion) exercise to bilateral upper and lower extremities every day for times a week as tolerated - for RNA to apply bilateral PRAFO (pressure relief ankle foot orthosis) four to six hours, every day five times a week, as tolerated. - for RNA to apply bilateral WHFO (wrist hand finger orthosis) four to six hours, every day five times a week, as tolerated. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to monitor the onset of weight loss for one final sampled resident (Resident 33) reviewed for nutrition. * The facility failed to address Resident 33's weight loss of 28 lbs in two days after admission and another weight loss of 3 lbs after three days. This failure had the potential for Resident 33's condition to go unmonitored and cause delay in treatment.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate care and services for the use of GT for two of four final sampled residents (Resident 27 and 72) and one nonsampled resident (Resident 54) reviewed for GT use. * The facility failed to ensure the physician's orders for the route of medication administration for Resident 27 was accurate. The medication route was ordered to be oral instead of the GT. * The facility failed to ensure a diet order was obtained from the physician for Residents 27, 54, and 72. * The facility failed to ensure Resident 27 and 72's HOB (head of bed) was elevated at a minimum of a 30 degree angle during the enteral feeding via GT, to reduce the risk of aspiration. These failures posed the risk of complications related to the use of the GT for Residents 27, 54, and 72.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the IV accesses for one nonsampled resident (Resident 45) who had peripheral IV (PIV) access. * The facility failed to properly label Resident 45's PIV access and discontinue the PIV catheter per the facility's P&P. This failure posed the risk of Resident 45 developing complications related to the use of the peripheral IV catheter.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services to meet the resident's needs for one of five final sampled residents (Resident 78) reviewed for unnecessary medications. * The facility failed to ensure Resident 78's enoxaparin (anticoagulant medication) injection sites were rotated. This failure had the potential for poor health outcome for Resident 78.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to identify and report a medication irregularity to the facility for one of 22 final sampled residents (Resident 42). * Resident 42 had a physician's order for docusate sodium medication; however, there was no specified dose indicated on the order. This failure posed the risk for Resident 42 to have adverse consequences from the medication. Findings. Review of the facility's P&P titled Medication Utilization and Prescribing- Clinical Protocol dated 4/2018 showed the consultant pharmacist should use the monthly and interim drug regimen review to help identify potentially problematic medications, including medications regimens that are not supported based on clinical signs and symptoms. [...]

Inspectors wrote2. Review of the facility's P&P titled Administering Medication through an Enteral Tube dated 11/2018 showed under the section preparation showed to verify that there is a physician's medication order for this procedure. Further review of the P&P showed to check the label, confirm the medication name and dose with the MAR . to calculate the medication dose and to re-check the calculation. On 6/3/25 at 0752 hours, a medication administration observation was conducted with LVN 1 for Resident 42. LVN 1 was observed preparing for the following medications in the seperate medication cup for each medication: - one tablet of docusate sodium (stool softener), 100 mg; - one tablet of pepcid (medication that treats and prevents heartburn from acid indigestion and upset stomach) 20 mg; - 5 ml of iron syrup (supplement), 220 mg/5 ml; - one tablet of folic acid (supplement), 1 mg; [...]

Inspectors wrote3. Review of the facility's P&P titled Storage of Medications revised 4/2019 showed the facility stores all the drugs and biologicals in a safe, secure, and orderly manner. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light, and humidity controls. On 6/2/25 at 0945 hours, a concurrent observation and interview was conducted with Resident 47 in her room. Resident 47 was observed with a clean dressing over her below the knee amputation stump. A clear medicine cup was observed filled with a dark liquid and placed on top of her nightstand. Resident 47 stated she did not know what was in the medicine cup. On 6/2/25 at 0950 hours, a concurrent observation and interview was conducted with the DON in Resident 47's room. The medicine cup was filled with a dark liquid was observed on Resident 47's nightstand. [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitation guidelines were followed as evidenced by: * The can opener blade's coating was observed to be removed. * Two frying pans were observed to have grayish black residue. * Strainer was observed to be with white residue. * An opened box of gloves was placed on top of plates where clean plates were stored. * The roof surface of the microwave used by residents was observed to be scattered food residue. These failures posed the risk for food borne illnesses for the 39 residents who consumed food prepared in the kitchen.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to dispose and store the trash in a sanitary manner. Three of four dumpster were observed overflowing with trash which prevented the lids from fully closing. This failure had the potential to harbor pests and for pest contamination. * Two of five dumpster bins were observed to be overflowing with trash which prevented the lids from fully closing. * Seven sharps' disposal containers were not properly disposed in the biohazard waste dumpster bins in the Infectious Waste Matter Room. These had the potential to attract and harbor pests and/ or rodents and potentially cause spread of diseases.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the medical records for two of 22 final sampled residents (Residents 58 and 33) were complete and accurate. * The facility failed to ensure Resident 58's physician's order dated 1/29/25, on NPO diet, NPO texture, NPO consistency was discontinued (NPO stands for nil per os or nothing by mouth). * The facility failed to ensure Resident 33's blood pressure access site was accurately documented in the resident's medical record. These failures had the potential for the residents' care needs not being met as their medical information was incomplete and inaccurate.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to implement the infection control program and practices designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases, for one final sampled resident (Resident 63) and five nonsampled residents (Residents 8, 21, 42, 66 and 79). * The facility failed to follow the physician's order for contact isolation, for Clostridium Difficile colitis, for Resident 63, as evidenced by the following. The facility failed to place Resident 63 in a private room. The LVN failed to utilize a designated blood pressure cuff and thermometer for Resident 63 while obtaining vital signs. The CNA failed to donn PPE in accordance with contact isolation precautions. [...]

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to offer the PCV 20, PCV 21, or PCV 15 (PCV 20 protects against 20 types of pneumococcal bacteria, PCV 15 protects against 15 types of pneumococcal bacteria, and PCV 21 protects against 21 types of pneumococcal bacteria), immunizations for one of five residents (Resident 15) reviewed for pneumococcal vaccination (a vaccine given to protect the resident from pneumococcal disease) in accordance with the CDC's recommendations. This failure increased the resident's risk for being inadequately vaccinated for the pneumococcal disease and its associated complications.

Inspectors wrote2. On 6/3/25 at 1148 hours, an observation and concurrent interview was conducted with RN 1. The refrigerator in the facility to store the residents' medication located in Medication Room A was observed with thick ice buildup in the frozen storage area. The frozen storage area was observed inside medication refrigerator with no separate door for the frozen storage area. Multiple medications for multiple residents were observed stored in the refrigerator. RN 1 verified the observations and stated the above refrigerator was being defrosted every month and acknowledged refrigerator needed more frequent defrosting. On 6/5/25 at 0933 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. [...]

Inspectors wrote2. Medical record review for Resident 19 was initiated on 6/2/25. Resident 19 was admitted to the facility on [DATE]. Review of Resident 19's Order Summary Report showed an order dated 7/3/23, for bilateral siderails as an enabler to promote independence and bed mobility. Review of Resident 19's care plan titled Use of Siderails dated 12/2/24, showed the risk and benefits of side rails including entrapment and other injury such as death, were explained to Resident 19 and her responsible party. On 6/2/25 at 0947 hours, an observation and concurrent interview was conducted with Resident 19. Resident 19 was observed lying in her bed with the bilateral side rails elevated. Resident 19 stated she utilized the siderails to reposition herself in bed. On 6/5/25 at 1418 hours, an observation was conducted of Resident 19. [...]

Inspectors wroteBased on interview and medical record review, the facility failed to accurately complete the MDS assessments for two of three residents reviewed for closed records (Residents 71 and 101). This failure had the potential to negatively affect the residents' well-being because the medical record information was not accurate.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of five sampled residents (Resident 3) was free from the unnecessary drugs. * The facility failed to ensure Resident 3's metoprolol tartrate (a beta-blocker, a medication a medication that works by affecting the nerve impulses in the body such as the heart and slows the heartbeat and decreases blood pressure) and hydralazine (medication used to treat high blood pressure) were administered as per the physician's orders. This failure had the potential for the resident to receive unnecessary medications and develop significant side effects.

Inspectors wroteBased on interview, facility document review, and facility P&P review, the facility failed to ensure Resident 4 was provided care in a manner that promoted dignity and respect. * The facility failed to consistently honor Resident 4's request not to assign CNA 1 for her ADL care needs. This failure had the potential to negatively impact the resident's psychosocial well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure one of four sampled residents (Resident 1) was free from accidents when the facility failed to follow their care plan requiring two-person assistance with bed mobility for Resident 1. * Resident 1 fell to the floor while being changed and turned in bed by one CNA. This failure resulted in Resident 1 falling to the floor with profuse bleeding from the head requiring Resident 1 to be transferred to the acute care hospital, which had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the staff implemented the proper storage, labeling, and disposal of medications in a safe manner as evidenced by: * The facility failed to ensure the medications were properly stored in Medication Cart A. In addition, thexpired medications and two blood glucose strip bottles were found in Medication Cart A. * The facility failed to dispose the expired [NAME] luer lock caps (use as a protective cap on access ports on medical devices or intravenous sets when not in use) inside Medication Cart C. * The facility failed to ensure the medications were not stored with the odor eliminator spray in Medication Cart B. [...]

Inspectors wroteBased on observation, interview, facility document review and facility P&P review, the facility failed to ensure 36 of 94 residents who received food from the kitchen received the proper diets and portion sizes when the facility's menus were not followed. * The facility failed to follow the menu for the BBQ Chicken puree recipe. * The facility failed to ensure the kitchen staff served the correct portion size as per the menu when serving the ground BBQ chicken and the potato salad. * The facility failed to ensure the residents who were on CCHO diets (diet for diabetics) received homemade BBQ sauce with their BBQ chicken as per the menu. These failures had the potential for the resident's nutritional needs not being met which could result in medical complications.

Inspectors wroteBased on observation, interview and facility document review, the facility failed to ensure the residents on mechanically altered diets received food in a form that met their individual needs when: 1. The pureed bread was not prepared according to the recipe. 2. One of 21 sampled residents (Resident 33) on a mechanical soft NAS (No added salt) CCHO (consistent carbohydrate- a diet to control blood sugar) diet received regular textured meat. 3. One of 73 nonsampled residents (Resident 29) on a mechanical soft finely chopped meat diet received a pureed diet. These failures posed the risk for complications such as choking for nine residents on mechanically altered diets: seven residents on a pureed diet and two residents on mechanical soft diets.

Inspectors wroteBased on observation, interview, medical record review, and facility document review, the facility failed to ensure the residents' entrapment assessments were complete and the measurements were recorded during the bed inspection when identifying areas of possible entrapment with the use of side rails for six of 21 final sampled residents (Residents 16, 18, 33, 61, 62, and 351). These failures had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death.

Inspectors wroteBased on observation, interview, medical record review, and facility document review, the facility failed to provide the residents' care timely for the residents on the SNF unit and two nonsampled residents (Residents A and 32). * The residents on the SNF unit were not repositioned or provided their usual care when only two CNAs were on duty. * Residents A and 32 waited more than an hour for incontinent care. These failures resulted in a delay of the residents' care, putting them at risk for negative outcome and resulting in feelings of discomfort.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide two of three final sampled residents reviewed for the Notice of Medicare Non-coverage (NOMNC) and Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) Form CMS-10055 (Residents 901 and 902). The NOMNC and SNF ABN Forms were used to inform the residents of their potential financial liability and appeal rights and protections should they wish to receive care and services that may not be covered by Medicare. This failure had the potential for not allowing Residents 901 and 902 to make an informed decision regarding their Medicare services.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to implement the restraint free periods for two of three final sampled residents reviewed for restraints (Residents 39 and 46). * The facility failed to ensure the mittens (mitten which look like boxing gloves with a Velcro or tie at the wrist to hold them in place and immobilize the resident's fingers) were released every two hours as per the resident's care plan and physician's order to release at least 10 minutes for Residents 39 and 46's both hands. These failures posed the risk of compromising the residents' independence and psychosocial well-being.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the comprehensive resident centered care plan was developed for one nonsampled residents (Resident 40) when the perishable and nonperishable food items were stored in Resident 40's room. This failure posed the risk to not provide appropriate, consistent, and individualized care.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the services provided met the professional standards of care when LVN 7 failed to properly administer the medication for one nonsampled resident (Resident 44). This failure had the potential to negatively impact the resident's health due to malabsorption and reduction in the effectiveness of the medication.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services for one of 21 final sampled residents (Resident 33) to ensure the residents maintained their highest physical well-being. * The facility failed to ensure the heel protector boots were applied to Resident 33's BLEs as per the physician's order. This failure had the potential to affect the resident's well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the RNA services as ordered by the physician for one of two final sampled residents reviewed for ROM functions (Resident 87). This failure had the potential for decline in the resident's range of motion and mobility.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure one of one final sampled resident reviewed for fall risks (Resident 23) remained free from accident hazards. The facility failed to implement the bilateral floor mats as per the physician's order and plan of care. This failure had the potential to place Resident 23 at risk for serious injury.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the IV accesses for two of two final sampled residents reviewed for IV care (Residents 53 and 67). * The facility failed to ensure the PICC line external catheter and arm circumference measurements were completed and documented in the medical record for Residents 53 and 67 upon admission to the facility. In addition, the facility failed to obtain a physician's order for care and maintenance of the PICC line, and failed to develop a plan of care for the use of PICC. These failures had the potential to delay the identification of catheter related complications for these residents.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the safe respiratory care to meet the needs for three of four final sampled residents (Residents 10, 16, and 53) and one nonsampled resident reviewed for respiratory care (Resident 51). * The facility failed to ensure Resident 16's ventilator machine alarms were set for high pressure alarms. In addition, the facility failed to ensure the nebulizer machine tubing was labeled. * The facility failed to ensure Resident 53's ventilator machine alarms were set for high pressure alarms. In addition, the facility failed to ensure the oxygen tubing labeled. * The facility failed to ensure Resident 10 received the amount of oxygen as ordered by the physician. * The facility failed to ensure Resident 51's oxygen concentrator was clean. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the dialysis care and services were provided for two of two final sampled residents reviewed for dialysis care (Residents 10 and 74). * The facility failed to ensure emergency supplies/kits were accessible at Resident 10's bedside in the event of dialysis (a treatment to rid the body of wastes and toxins when the kidneys fail to function) access bleeding/emergency. * The facility failed to ensure Resident 74's emergency dialysis kit was available at the bedside. These failures had the potential for Residents 10 and 74 not being provided appropriate care and treatment, and possibility of medical complications.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the pharmaceutical services to meet the resident's needs for one of 21 final sampled residents (Resident 39). * The facility failed to ensure Resident 39's lorazepam (antianxiety medication) was accurately reconciled. The lorazepam tablets removed as shown on the Record of Controlled Substances was not recorded as administered on the electronic MAR. This failure had the potential for drug diversion.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure two of five final sampled residents sampled reviewed for unnecessary medications (Residents 25 and 42) were free from unnecessary psychotropic drugs (any drug that affects brain activity associated with mental processes and behavior). * The facility failed to ensure the informed consent was obtained from Resident 42 for the use of Seroquel (quetiapine fumarate, an antipsychotic medication). In addition, the facility failed to ensure the non-pharmacological interventions were implemented prior to administering Resident 42's Seroquel. * The facility failed to ensure Resident 25's informed consent for diazepam (an antianxiety medication) was signed and dated by the physician. These failures had the potential for the residents receiving the unnecessary psychotropic medications.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 6.06%. Two of the four licensed nurses (LVNs 6 and 7) who were observed during the medication administration were found to have made errors. * LVN 6 failed to ensure Resident 12's vitamin B12 (supplement) was administered as ordered. * LVN 7 failed to ensure Resident 44's aspirin was administered as ordered. These failures had the potential to negatively impact the residents' health and safety and posed the risk for possible complications.

Inspectors wroteBased on observation, interview and facility document review, the facility failed to provide the food substitute of similar nutritive value when the meal alternate recipes were not followed for four of 36 sampled residents who received meals from the kitchen (Residents 13, 21, 32, and 80). This failure had the potential for Residents 13, 21, 32, and 80 who received a meal alternate from the kitchen to not meet their nutritional needs.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the food safety guidelines were met in the kitchen as evidenced by: * The facility failed to ensure Time Temperature Control for Safety (TCS) Food (food that require time and temperature controls to limit the growth of illness causing bacteria) were monitored with a cool down log. * Resident 40's room was observed with non-perishable and perishable food items brought from the outside. The food items were not labeled and dated and the mini fridge with perishable food was not being monitored by the facility. * The residents' food items brought from outside were not labeled and dated. * The facility failed to ensure the ice machine drainpipe located in the kitchen had an air gap. [...]

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the P&P regarding outside food for residents was followed. * The facility failed to ensure the facility staff responsible for handling food brought for the residents from the outside and visitors who brought food for residents from the outside were educated on safe food handling procedures. * The facility failed to provide appropriate equipment needed to reheat food items brought in for residents from the outside. These failures posed the risk for food borne illness in residents who consume food from outside sources.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the medical records for three of 21 final sampled residents (Residents 23, 25, and 61) were complete and accurate. * The facility failed to ensure Resident 23's CNA flowsheet for meal percentages and nourishments were complete and accurately documented. * The facility failed to ensure Resident 25's Advance Directive Acknowledgment form was complete to reflect Resident 25's wishes; and failed to ensure Resident 25's informed consent for Xanax (an antianxiety medication) had the correct date as the physician's order date. * The facility failed to ensure Resident 61's POLST information had the same information with the Advance Directive Acknowledgement form. These failures had the potential for the residents' care needs not being met as their medical information was incomplete and inaccurate.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the appropriate infection control practices designed to provide a safe and sanitary environment and to prevent the spread of infections within the facility were implemented. * Resident 17's urinary tubing and Resident 81's indwelling catheter drainage bag were laying on the floor. * One of two clean linen wheeled bins had layers of peeling tape on the hard plastic cart. These failures posed the risk of transmission of nfectious organisms from the floor to the urinary tract and transmission of infection in the facility.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the essential kitchen equipment was maintained in safe operation condition when the ice machine manufacturer cleaning and sanitizing instructions were not followed. This failure had the potential to result in the equipment to not function in the way it was intended which could affect the health status of the residents.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the kitchen was free of pests. This failure posed the risk for pests to transmit disease to residents by contaminating food and food contact surfaces for 36 residents who received food prepared in the kitchen.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to maintain the clean, sanitary, and homelike environment for one of 10 restrooms observed. * Resident 84's restroom was observed with multiple streaks of yellow stain on the wall near the mirror and sink. In addition, the restroom's floor was also observed with multiple brown circular stains. This failure posed the risk for unsanitary conditions and a negatively effect on Resident 84's well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P, the facility failed to ensure the comprehensive plan of care for one of four final sampled residents reviewed for care plans (Resident 25) was revised to reflect the resident's current care needs and interventions. * Resident 25's care plan for behavior of anxiety manifested by inability to relax was not revised to address the new order for diazepam (an antianxiety medication). This posed the risk of not providing the resident with individualized and person-centered care.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide a homelike environment by maintaining the comfortable sound levels for one of six sampled residents (Resident 3). * Resident 3's roommates (Residents A and B) had caused the disruption due to their noise levels and Resident 3 reported the noise issue to the staff and subsequently requested a room change; however, there was no resolution or follow up to Resident 3's concern. This failure had to the potential for Resident 3 to continuously have interruption of sleep and disrupting their homelike environment. Findings a. Medical Record Review for Resident 3 was initiated on 3/25/24. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's H&P examination dated 9/21/23, showed Resident 3 could make needs known but was unable to make medical decisions. b. [...]

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to implement the P&P for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when the facility did not report an allegation of verbal abuse to the CDPH, L&C Program, Ombudsman Office, and local law enforcement agency for one of two sampled residents (Resident 1). This failure had the potential for Resident 1 to be vulnerable to further abuse and emotional distress.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure four of four nonsampled residents (Residents 51, 58, 73, and 80) were free from the physical restraints. The facility to ensure the least restrictive measures were attempted prior to the use of hand mittens. This failure had the potential to result in compromising Residents 51, 58, 73, and 80's independence and psychological well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to develop the plans of care to reflect the individual care needs for four of four nonsampled residents (Residents 51, 58, 73, and 80). This posed the risk of not providing appropriate, consistent, and individualized care to these residents.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen as evidenced by: * The facility failed to ensure the ice machine drain pipe had an air gap and not touching the drain. * The facility failed to ensure the sanitary condition of the hood over the stove was maintained. * The facility failed to ensure the kitchen utensils had smooth cleanable surface. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure three of 19 final sampled residents (Residents 39, 46, and 340) were assessed to self-administer their medications. This had the potential for Residents 39, 46, and 340 to have medication administration errors.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to determine whether one of 19 final sampled residents (Resident 49) wished to formulate an advance directive. This had the potential for the resident's decisions regarding his health care and treatment options not being honored.

Inspectors wroteBased on observation and interview, the facility failed to maintain a clean, safe, and homelike environment for two of 19 final sampled residents (Residents 49 and 62). * Residents 49 and 62 were roommates. The residents' room (Room A) was observed with stained areas on the ceiling above Resident 62's bed and the wall was observed in a state of disrepair with exposed sharp edges. * Resident Room B was observed with the wall baseboard protruding out from the wall. These failures had the potential to negatively impact the residents' safety and quality of life.

Inspectors wroteBased on interview and medical record review, the facility failed to accurately code the MDS for one of 19 final sampled residents (Resident 58). The facility failed to ensure Residents 58's diagnosis of schizophrenia (a severe brain disorder in which people interpret reality abnormally) was coded accurately. This failure posed the risk of the resident not receiving an individualized plan of care based on the resident's specific needs.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the level 1 PASRR (used to ensure a resident with a mental illness is evaluated and receives care in a setting appropriate to meet their needs) contained accurate information for one of 19 final sampled residents (Resident 3). * Resident 3 had a diagnosis of depression and was prescribed citalopram (antidepressant medication); however, the level 1 PASRR screen showed Resident 3 had no diagnosis of mental illness and was not prescribed with psychotropic medications. [...]

Inspectors wroteBased on interview and medical record review, the facility failed to ensure a care and services provided meeting the accepted standards of quality for one of 19 final sampled residents (Resident 58). * Resident 58 was diagnosed with schizophrenia (a severe brain disorder in which people interpret reality abnormally) without a complete clinical assessment and was prescribed with an antipsychotic medication. This failure posed the risk and the potential for the resident to suffer the adverse effects of the antipsychotic medication prescribed.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to accommodate the needs for one of 19 sampled residents (Resident 27). * A Vietnamese communication board was not available when required by Resident 27 for communication. This has the potential to impede the resident in maintaining and/or achieving independent functioning, dignity, and well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the needed care and services for two of 19 sampled Resident (Residents 27 and 340). * Resident 340 had developed multiple skin discolorations; however, the direct care staff failed to report these skin discolorations to the licensed nurses to conduct a thorough assessments and obtain orders for appropriate treatment. Failure to report and assess areas of skin discoloration in a timely manner placed this resident at increased risk for further injury to their skin. * Resident 27 had reported to the licensed nurse about lower eyelids' discomfort and redness, but the license nurse did not communicate in timely manner with the hospice staff and other staff to address the issue. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the wound care in a manner to prevent infection of wound for one of 19 final sampled residents (Resident 17). LVN 7 failed to maintain a clean field during the preparation of Resident 17's wound care supplies and treatment. This posed the risk of cross contamination and the potential for wound infection.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure one of 19 final sampled residents (Resident 62) remained free from accident hazards. * The wall located adjacent to the head of Resident 62's bed was observed in disrepair with exposed sharp edges. This failure had the potential to place the resident at risk for serious injury.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being for one of 19 sampled residents (Resident 43). * The facility failed to completely assess Resident 43 for pain prior to administering morphine (an opioid pain medication), creating the risk for the resident's pain not being properly managed.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure one of 19 final sampled residents (Resident 26) remained free from accident hazards due to the use of elevated side rails. * The facility failed to attempt alternatives prior to the use of elevated side rails for Resident 26. This had the potential to place the resident at risk for entrapment and serious injury.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the individualized behavioral health care needs and services for one of 19 final sampled residents (Resident 58) were met. * Resident 58 was diagnosed with schizophrenia (a severe brain disorder in which people interpret reality abnormally) without a thorough clinical assessment and was prescribed a Seroquel (antipsychotic medication). The pharmacological interventions was used when the clinical psychological assessment was not thoroughly done. This failure had the potential for the resident not able to attain her highest practicable well being.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure one of 19 final sampled residents (Resident 58) was free from unnecessary psychotropic medications. This failure had the potential for the resident to experience adverse consequences from the psychotropic medications.

Inspectors wroteBased on observation and interview, the facility failed to ensure garbage was properly stored in three of three garbage dumpsters. The failure of the facility to ensure the garbage was contained and covered had the potential to attract pest/rodents that carried disease.

Inspectors wroteBased on interview and facility record review, the facility failed to comply with the State regulation for not submitting a written notice timely to the Stage Agency responsible for licensing the facility when the facility had a changes of the facility's Administrator. * The facility's new Administrator began employment at the facility on 3/1/23; however, the facility had yet to notify the State Agency. This failure had the potential to cause confusion specific to communication between the State Agency and facility's administrative staff.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the medical records for two of 19 final sampled residents (Residents 19 and 70) were accurate and complete. This failure had the potential for the residents' care needs not being met as their medical information was incomplete.

Inspectors wroteBased on observation and interview, the facility failed to ensure the call light for Resident 43 was operable. This posed the risk for staff not knowing and answering the calls for the residents needed assistance in the room.