Hyde Park Healthcare Center

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the physician or Medical Director (MD) was notified, for one of three sample residents (Resident 1), who had changes of condition (COC). Resident 1 had swelling to the right forearm on 6/22/2026 and a right radius fracture (a break in the larger forearm bone near the wrist) on 6/24/2026. This deficient practice resulted in a delay in care and treatment for Resident 1.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement the Care Plan for one of three sample residents (Resident 4), which indicated to maintain one-to-one (one staff delegated to supervise a single resident) monitoring and provide supervision and redirection for Resident 4, who had increased wandering behavior. This deficient practice resulted in Resident 5 pushing Resident 4 to the ground when Resident 4 wandered into Resident 5's room and placed Resident 4 at risk for injuries and on-going resident altercations.

Inspectors wroteBased on interview and record review, for one of two residents (Resident 4), the facility failed to review, revise or provide interventions in the resident's care plan titled, Wound Management Post-Surgical right hand index finger-General, to achieve goals for the resident's care. This failure had the potential for Resident 4 to receive poor quality care and placing the right-hand index finger post-surgical wound at risk for delayed wound healing and infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three residents' (Resident 4) urinal (a portable, handheld urine bottle used by bedridden or immobile individuals in healthcare settings) was labeled. This failure had the potential for accidental use of the urinal for another resident, leading to the spread of bacterial infections or cross contamination (the process by which bacteria (germs) or other micororganisms (germs) are unintentionally transferred from one substance or object to another, with harmful effect).

Inspectors wroteBased on interview and record review, the facility failed to ensure the personal funds for one of four sampled residents (Resident 1) was safeguarded from misappropriation (the deliberate misplacement, wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent) by failing to ensure the Business Office Manager (BOM) did not take Resident 1's personal funds out of the facility and kept them in her personal possession without Resident 1's authorization. This deficient practice had the potential to result in financial abuse or misappropriation of funds affecting Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to follow its Policy and Procedure (P&P) titled, Abuse and Neglect Prohibition Policy which indicated the facility will report all allegations of misappropriation of funds (the deliberate misplacement, wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent) to the Licensing and Certification Program District Office (CDPH) within two hours for one of four sampled residents (Resident 1), when Resident 1's personal funds were taken by the Business Office Manager (BOM) without the Resident's authorization. This deficient practice resulted in a delay in the investigation by the CDPH and had the potential to result in continued abuse of Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to follow its Policy and Procedure (P&P) titled, Abuse and Neglect Prohibition Policy which indicated the facility will report all allegations of abuse to the Licensing and Certification Program District Office (State Agency) within two hours, for one of six sampled residents (Resident 1), after a General Acute Care Hospital (GACH) staff notified the facility on 6/4/2026 of Resident 1's allegation that unidentified staff abused her and did not feed her (date not specified). This deficient practice resulted in a delay in the investigation by the State Agency and placed Resident 1 at risk for continued abuse or neglect.

Inspectors wroteBased on interview and record review, the facility failed to investigate an allegation of abuse for one of six sampled residents (Resident 1), when a General Acute Care Hospital (GACH) staff reported to the facility on 6/4/2026, of Resident 1's allegation that (unidentified) staff abused her and did not feed her (date not specified). This deficient practice had the potential to result in unidentified abuse towards Resident 1 and could negatively affect the Resident's well being. Based on interview and record review, the facility failed to investigate an allegation of abuse for one of six sampled residents (Resident 1), when a General Acute Care Hospital (GACH) staff reported to the facility on 6/4/2026, of Resident 1's allegation that (unidentified) staff abused her and did not feed her (date not specified). [...]

Inspectors wroteBased on interview and record review, the facility failed to provide supervision for one of six sampled residents (Resident 5), who was a high risk for fall and required contact guard assistance (CGA- a level of physical assistance where staff maintains light, hands-on contact with the resident for stability, balance and fall prevention) from staff when walking. This deficient practice resulted in Resident 5 falling in the hallway on 6/8/2026 after walking out of the shower room unassisted and placed the Resident at risk for injury.

Inspectors wroteBased on interviews and record review, the facility failed to ensure a resident-centered care plan with interventions were developed when: 1). Two of six residents (Residents 4 and 5) who were involved in a resident-to-resident interaction on 5/20/2026 had refused room changes. This deficient practice had the potential to result in further altercations, placing both residents at risk for serious physical injuries which could lead to hospitalizations. 2). Resident 6 had an actual fall on 5/14/2026. This failure placed the resident without safety interventions, placing the resident at risk for a recurrent fall.

Inspectors wroteBased on interview and record review, the facility failed to meet professional standards of care by failing to carry out radiology (xray, process of taking pictures to diagnose and treat diseases) test, ordered by the physician for one of six residents (Resident 6), who fell on 5/14/2026. This failure had the potential to delay identification of any broken bones and in providing treatment necessary for the resident's care.

Inspectors wroteBased on interview, and record review, the facility failed to ensure medications ordered by the physician for one of six residents (Resident 1), were administered within 60 minutes of the scheduled time as indicated in the facility's policy and procedure (P&P) titled Medication Administration -General Guidelines. This failure placed the residents at risk for health complications and increased risk of hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five residents (Resident 3), was not subjected to physical abuse (the willful infliction of physical pain, injury, which includes hitting, slapping, pinching, kicking, etc.) by Resident 5. The facility failed to: Provide nursing interventions on 4/5/2026 at 8:10 a.m. to prevent resident's agitation (a state of severe restlessness, tension, or nervous excitement) from escalating (increase), when Resident 5 threw the phone at a staff at the nurse's station, then walked to his room, removed a breakfast tray from the cart and threw onto the floor, stating, I want to go to the hospital now. [...]

Inspectors wroteBased on interview and record review, the facility failed to update one of three residents' (Resident 1's) care plan after the diet order was changed. This failure had the potential for Resident 1's care team to follow an old intervention resulting to providing the incorrect diet texture, placing the resident at risk for choking, hospitalization and death.

Inspectors wroteBased on interview and record review, the facility failed to meet professional standards of quality by failing to ensure the Complete Blood Count (CBC - laboratory blood test that measures the cells circulating in blood) ordered by the physician for one of three resident's (Resident 2), was done as ordered. This failure had the potential for delayed identification of the resident's current medical condition and delay the necessary care and interventions the resident will need and placed the resident at risk for worsening condition and hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four (4) residents (Resident 1), was provided with interventions to reduce the risk of recurrent fall, as indicated in the facility's policy and procedure (P&P) titled Fall Prevention Program. As a result, Resident 1 had a total of 4 fall incidents since admission on [DATE], 1/23/2026, 2/18/2026 and 2/21/2026, placing the resident at risk for severe injuries, including hospitalization and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its policy and procedure (P/P) titled Abuse and Neglect Prohibition Policy, dated 6/2022, which indicated the facility prohibited abuse for all residents, for one of four sampled residents (Resident 1), who lacked the ability to consent and had severe cognitive impairment (a profound decline in thinking, memory, and reasoning, that prevents independent living). Resident 2, who had a history of sexually inappropriate behaviors sexually assaulted Resident 1. This deficient practice resulted in Resident 2 forcing penile-vaginal penetration onto Resident 1 on 1/17/2026. [...]

Inspectors wroteBased on interview and record review, the facility failed to conduct a thorough investigation following an allegation of staff-to-resident sexual misconduct for one of four sampled residents (Resident 4). This deficient practice placed Resident 4, and all other facility residents, at risk for the occurrence of repeat staff-to-resident sexual misconduct.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care and services consistent with professional standards of practice for one of seven Residents (Resident 1) by failing to ensure:Licensed nurses clarified Resident 1's oxygen (O2) orders when the physician ordered O2 3 liters per minute (l/min) every shift for Resident 1 without indicating frequency (to be administered continuously or as needed). This deficient practice had the potential to result in respiratory failure (a condition in which the respiratory system cannot maintain adequate gas exchange, leading to insufficient oxygen in the tissues [hypoxia]) for Resident 1 and could negatively impact the Residents' health and safety.

Inspectors wroteBased on interview and record review, the facility failed to ensure telephone orders given by the ordering physician, telephone orders obtained by staff from the ordering physician and other orders given by the ordering physician, were entered under the prescriber's name. This failure resulted in the difficulty in identifying the ordering physician's name, had the potential to mislead the healthcare system and potential for fraud.

Inspectors wroteBased on interview and record review, the facility failed to report to the California Department of Public Health (CDPH), when one of ten sampled residents (Resident 5), allegedly hit Resident 4 in the stomach since admission to the facility on [DATE]. This deficient practice resulted in a delay in investigation by the CDPH and placed Resident 4 at risk for physical abuse (any intentional act causing injury or trauma to another person through bodily contact, including, but not limited to, hitting, slapping, punching, biting and kicking).

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure (P&P) titled admission to the Facility, when the admission consent for one of three residents (Resident 4), was not obtained from the resident or family representative. This deficient practice resulted in the resident's admission to the facility without consent and had the potential that the affected resident will not receive the necessary care and services the resident need.

Inspectors wroteBased on interview and record review, the facility failed to provide Bed-Hold (refers to the practice where a resident's bed is reserved for 7 days while temporarily away from the facility, such as during hospitalization or therapeutic visits) written notification to one of three residents (Resident 1), when Resident 1 was transferred to the general acute care hospital on [DATE], 12/8/2025, 12/11/2025, and 12/14/2025, as indicated in its policy and procedure (P&P) titled, Bed-Hold. This failure had the potential for Resident 1 not to exercise the option to use the facility's bed-hold policy and lose their bed at the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure care and services for two of three sampled residents (Residents 1 and 3) who had seizure disorders (a sudden, uncontrolled electrical disturbance in the brain), met professional standards of quality care. These failures had the potential for recurring seizures, injuries, hospitalization and death.

Inspectors wroteBased on interview and record review, the facility failed to ensure admission orders (orders containing treatment and medications to be administered to the resident being admitted to the facility) for one of three newly admitted residents (Resident 4), were obtained from a physician, as indicated in its policy and procedures (P&P) titled, admission to the Facility. This deficient practice resulted in Resident 4's admitting orders not verified from the physician. This deficient practice had the potential for wrong name of medications ordered, wrong dosage, wrong route and placing the resident at risk receiving the wrong drugs, that could affect the resident's medical condition, leading to injuries, hospitalization or death.

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician was called to follow up admission medication orders for one of three newly admitted residents (Resident 4), for timely administration. This deficient practice resulted in the delayed administration of medications due and had the potential to affect the resident's medical condition, leading to complications, hospitalization and death.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident was free from physical abuse when was pushed to the floor by another resident and sustained an injury for one of four sampled residents (Resident 1). These deficient practices resulted in Resident 2 on 11/30/2025 pushing Resident 1 to the floor and sustaining a 1.0-inch posterior (back of the head) scalp (skin covering the head) laceration (skin tear) which required evaluation and treatment in a general acute care hospital (GACH). Resident 1 received two staples (a piece of thin wire with a long center portion and two short end pieces) for the scalp laceration.

Inspectors wroteBased on interview and record review the facility failed to ensure licensed nurses followed up with the facility's contracted pharmacy on a physician's order dated 11/23/2025 for Seroquel (antipsychotic [medication that manage psychosis {hallucinations, delusions, disordered thinking}] medication primarily used to treat schizophrenia [a mental illness that is characterized by disturbances in thought] and bipolar [mood swings that range from the lows of depression to elevated periods of emotional highs] disorder) 25 milligrams (mg-unit of weight measurement) for one of three sampled residents (Resident 2) to ensure the medication was obtained and administered to Resident 2 in timely manner and as ordered to manage Resident 2's aggressive behavior to prevent Resident 2's angry outburst resulted in Resident 1's physical abuse. Resident 2 did not receive Seroquel for eight days. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure Registered Nurses (RN), RN 1, RN 2, and Licensed Vocational Nurses (LVN), LVN 3, LVN 4, LVN 5, LVN 6, LVN 7 did not willfully falsify Resident 2's medical records when the staff documented administration, resident refusal, and awaiting pharmacy of ordered psychotropic medication that was not available in the facility for Resident 2. This deficient practice resulted in Resident 2 having inaccurate medical records that did not reflect the actual care provided or his actual clinical condition.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of five (5) sampled residents (Resident 1), who was confused with diagnoses including schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions), suicidal ideations (thoughts, wishes, or preoccupations with death or self-harm), bipolar disorder (a mental condition marked by alternating periods of elation and depression), major depressive disorder (mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities) and diabetes mellitus (DM, abnormal blood sugar level), did not elope from the facility on 9/25/2025. The facility failed to: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to:1. Follow Enhanced Barrier Precautions ([EBP] - an infection control intervention designed to reduce transmission of multi-drug-resistant organisms) for one of four sampled residents (Resident 4). This deficient practice had the potential to result in cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) and an increased risk of developing and spreading infection to Resident 4 and other residents and staff in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) personal possessions were properly inventoried and accounted during admission to the facility. This failure had the potential to violate the resident's right to respect residents' personal possessions.

Inspectors wroteBased on interview and record review, the facility failed to report the Ombudsman's (Patient advocate) allegation of neglect (failure of the facility to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress, which occurs when the facility is aware of, or should have been aware of goods or services that a resident[s] requires but the facility fails to provide them to the resident[s], resulting in, or may result in, physical harm, pain, mental anguish, or emotional distress) to the California Department of Public Health (CDPH), for one out of four sampled residents (Resident 1), alleging staff did not provide basic services such as bathing, shaving and offering urinal. This deficient practice resulted in delayed investigation by the CDPH and placed Resident 1 and other residents at risk for further neglect.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Pharmaceutical Services Policy and Procedure Manual, by failing to ensure one of three sampled residents' (Resident 1) medications ordered by the physician, were administered within 60 minutes of scheduled time. This deficient practice resulted in the delay for Resident 1 to receive scheduled medications and had the potential for the medications to be ineffective. This deficient practice also had the potential to administer hypertension [HTN], high blood pressure) medications ordered twice a day, close to the next dose, causing the blood pressure to drop lower, resulting in hospitalization and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its Policy and Procedure (P&P) titled, Scope of Infection Control Program, which indicated standard precaution (the basic level of infection prevention and control practices used in healthcare settings to minimize the transmission of infections) and hand hygiene should be followed to prevent the spread of infections to 1 of 3 sampled residents, (Resident 1) during wound care procedure. This failure had the potential to result in cross contamination and spread of bacteria and other microorganisms causing wound infections and other complications of infections leading to hospitalization.

Inspectors wroteBased on observation, interview and record review, for three (3) of 3 sampled residents (Residents 1, 3 and 4), the facility failed to:1). Ensure Resident 3's call light was in working condition.2). Ensure Residents 1 and 4's call lights were placed within reach.3). Ensure Resident 4, who needed staff assistance and whose call light was turned on, was answered in a timely manner. These deficient practices had the potential that the needs of the residents will not be attended to timely. These deficient practices had the potential to result in falls and injuries, and other severe complications in cases of an emergency situation. This deficient practice resulted in Resident 4's needs not assisted timely and had the potential to affect the resident's psychosocial well-being causing the resident's feeling of desperation (despair) and neglect.

Inspectors wroteBased on interview and record review, the facility failed to ensure a safe discharge planning process for one of four sampled residents, Resident 1. This failure had the potential for unsafe discharge by not identifying the resident's discharge needs and not thoroughly planned and prepared, and communicated to the receiving facility. This failure caused Resident 1 to feel anxious and sad and had the potential to affect the resident's highest practicable physical, mental and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure PRN (as needed) orders for Zyprexa (antipsychotic medications used to treat mental illness) were limited to a 14-day duration between 3/6/25 and 4/16/25 in one of five residents sampled for unnecessary medications (Resident 118.) 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to: 1. Complete and re-submit the Preadmission Screening and Resident Review ([PASARR - a tool to determine if the person had, or was suspected of having a mental illness, intellectual disability, or related condition) Level one (I) screening and refer to the appropriate state-designated authority for PASARR Level two (II) evaluation and determination for two of seven sampled residents (Resident 13 and Resident 46). This deficient practice had the potential to result in Resident 13 and 46 to not receive the appropriate medical treatments for mental illness diagnosis.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Develop a comprehensive plan of care (resident-specific plans of care developed to address a specific problem or resident need) to address a diagnosis of anxiety (a mental illness characterized by constant worries persistent enough to interfere with everyday life) and behaviors of inability to relax related to the use of Ativan (an anti-anxiety medication used to treat mental illness) in one of five residents sampled for unnecessary medications (Resident 13.) The deficient practices of failing to create a comprehensive care plan to address Resident 13 ' s diagnosis of anxiety and behavior of inability to relax related to the use of psychotropic medications (medications that affect brain activities associated with mental processes and behavior) increased the risk that Residents 13 could have experienced adverse effects [...]

Inspectors wroteB. During a review of Resident 56's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 56 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 56's diagnoses included metabolic encephalopathy (a change in how your brain works due to an underlying condition), dementia (a progressive state of decline in mental abilities), and nicotine (substance found in tobacco products). During a review of Resident 56's History and Physical (H&P), the H&P indicated, Resident 56 could make needs known but did not have the capacity to consent. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain complete records of non-narcotic (medications other than those controlled for an increased risk of abuse) destruction logs by failing to have a licensed nurse and a witness sign the destruction logs in one of one inspected medication rooms (Station 1 Medication Room.) The deficient practice of failing to ensure a licensed nurse and witness sign off on the non-narcotic destruction logs increased the risk of drug diversion (any use of a medication for reasons other than those intended by the prescriber) or accidental exposure to the facility ' s residents possibly leading to medical complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%). Three errors out of 26 opportunities contributed to an overall error rate of 11.54 % affecting two of four residents observed for medication administration (Resident 32 and Resident 40.). The errors noted were as follows: 1. Incorrect dose of calcium carbonate (a supplement) administered to Resident 32 2. Incorrect formulation of multivitamins (a supplement) administered to Resident 40 3. Incorrect dose of Seroquel (a medication used to treat mental illness) administered to Resident 40. The deficient practice of failing to administer medications in accordance with the physician ' s orders increased the risk that Residents 32 and 40 may have experienced medical complications possibly resulting in hospitalization.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Store one unopened vial of latanoprost eye drops (a medication used to treat eye conditions) in the refrigerator according to the manufacturer's instructions affecting Resident 2 in one of two inspected medication carts (Station 2 Cart.) 2. Store two unopened Lantus insulin pens (a medication used to treat high blood sugar) in the refrigerator according to the manufacturer's instructions affecting Residents 30 and 216 in one of two inspected medication carts (Station 1 Cart.) The deficient practices of failing to store medications per the manufacturers ' requirements increased the risk that Residents 2, 20, and 216 could have received medication that had become ineffective or toxic due to improper storage possibly leading to health complications resulting in hospitalization or death.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure one of 17 sampled residents (Resident 167) participated in care plan meetings. This deficient practice violated Resident 167's rights to be fully informed of the resident's plan of care and had the potential to result in delay of care and services.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure a foley catheter (a flexible plastic tube inserted into the bladder to provide continuous urinary drainage) privacy drainage bag was provided for one of one sampled resident (Resident 20). This deficient practice had the potential for Resident 20 to feel embarrassed.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Report to the California Department of Public Health (CDPH- the state department responsible for public health in California) of a resident-to-resident altercation in a timely manner to CDPH for 2 of 3 sampled residents (Resident 118 and Resident 59). This deficient practice resulted in a delay in investigation by CDPH and placed Resident 2, Resident 3 and other residents at risk for further abuse.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Transmit the Discharge Minimum Data Set ([MDS]- a resident assessment tool) Assessment within 14 days after completion to Center of Medicare and Medicaid Services (CMS) for one of one sampled resident (Resident 15). This deficient practice had the potential to result in billing error and inaccurate data on resident care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Submit a Pre-admission Screening and Record Review (PASARR) for one of four sampled residents (Resident 47). This deficient practice had the potential to result in a delay of necessary care and mental health services.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Develop a baseline care plan for one of 17 sampled residents (Resident 167). This deficient practice had the potential for Resident 167 to not receive appropriate care and treatment specific to her needs.

Inspectors wroteBased on observation and interview, the facility failed to: 1. Ensure a low air loss mattress (a specialized type of medical air mattress designed to prevent and treat pressure injuries (bedsores) by reducing moisture and heat buildup on the skin) was provided for one of four sampled residents (Resident 46). This deficient practice had the potential to result in further skin breakdown.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure an appointment for urology (branch of medicine that focuses on surgical and medical diseases of the urinary system and the reproductive organs) evaluation/referral was completed for one of one sampled resident (Resident 20). This deficient practice had the potential to result in the delay of necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure the initial and annual competency checklists were completed for one of four sampled employees (Certified Nurse Assistant [CNA] 3). This failure had the potential to negatively affect the residents' quality of care.

Inspectors wroteBased on interview and record review, the facility failed to respond to the consultant pharmacist ' s recommendation (monthly recommendations by a pharmacist concerning potential medication-related irregularities), dated 3/23/25, to limit PRN (as needed) orders for Zyprexa (antipsychotic medications used to treat mental illness) to a 14-day duration in one of five residents sampled for unnecessary medications (Resident 118.) The deficient practices of failing to respond to the consultant pharmacist ' s recommendation to limit PRN orders for antipsychotic medications to 14-days increased the risk that Resident 118 could have experienced adverse effects related to antipsychotic medication therapy, such as drowsiness, dizziness, constipation, or increased risk of fall, possibly leading to impairment or decline in his mental or physical condition or functional or psychosocial status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free of significant medication errors by administering the incorrect dose of Seroquel (a medication used to treat mental illness) on 6/25/25 to one of four residents observed for medication administration (Resident 40.) The deficient practice of failing to administer medications in accordance with the physician ' s orders increased the risk that Resident 40 may have experienced medical complications possibly resulting in hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure one of five sampled residents (Resident 38) had a Levetiracetam level (a blood test to check the amount of this drug in your body) completed every three months. This deficient practice had the potential to result in Resident 38 having a seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) if the levels were not in range.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure the documentation was complete and x-ray result for one of one sampled resident (Resident 56) was accessible and filed in medical records. This deficient practice had the potential to place Resident 56 at risk of not receiving appropriate care and delay in communication among staff due to incomplete medical records.

Inspectors wroteBased on observation and interview, the facility failed to ensure staff disinfected blood pressure cuffs before and after use during medication administration affecting two of four residents observed for medication administration (Residents 32 and 40.) The deficient practice of failing to disinfect shared medical equipment before and after use on different residents increased the risk that Residents 32 and 40 could have developed an infection (the invasion and growth of germs in the body) causing medical complications possibly leading to hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure residents in rooms 101, 102, 103, 104, 105, 106, 107, 109, 110, 111, 112, 114, 115, 116, 117, 118, 119, 120, 121,122, 123, 126, and 127 had at least 80 square feet ([sqft]- a unit of measure) of living space. This deficient practice had the potential to result in residents not being able to move around freely or store personal items. Staff may also have difficulty providing care due to a lack of space.

Inspectors wroteBased on interview and record review, the facility failed to safely discharge on e of three sampled residents (Resident 1) when: 1. The facility discharged Resident 1 from the facility, without his knowledge, request, or consent, against medical advice (AMA), on 5/2/2025. This deficient practice placed the resident at risk for avoidable physical and psychosocial harm due to their discharge without confirmation of his whereabouts and/or safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of seven sampled Residents (Resident 3 and Resident 7) were provided a clean homelike environment by failing to ensure the residents bed linen were changed daily or when soiled. This deficient practice had the potential to spread of infection and placed the residents at risk for physical discomfort.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services to prevent a fall for one of three sampled residents (Resident 1) by failing to: 1. Ensure Certified Nursing Assistant (CNA) 1 provided a two-person physical assist (help from two persons) when using a Hoyer Lift (mechanical lift- a device used to transfer residents from a bed to a chair or other similar places) to transfer Resident 1 from the bed to a Geri-chair (padded chair to provide comfort and support for people with limited mobility). This deficient practice caused Resident 1 to fall and sustain an acute (immediate) fracture (broken bone) of the right femoral neck (part of the thigh bone below the hip joint). Resident 1 was transferred to a general acute care hospital (GACH) for evaluation and treatment five days after the fall.

Inspectors wroteBased on interview and record review, the facility failed to report to the California Department of Public Health (CDPH), a fall that resulted in a hip fracture (broken bone) after it was reported to the facility by a general acute care hospital (GACH). This deficient practice had the potential to lead to severe complications, including prolonged pain, blood clots (semi-solid masses that form and could block blood flow), and potentially death.

Inspectors wroteBased on observation, interview, and record review, the facility did not provide a safe and homelike environment for four of four sampled residents (Residents 1, 2, 3, 4) when flies were present in resident rooms. This failure resulted in residents feeling unhygienic (dirty) and dehumanized (degrade).

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure (P&P) titled Residents' Personal Property, when a grievance (complaint) was not filed, and an investigation not conducted, when one of four residents (Resident 3), reported belongings were missing. This failure resulted in a violation of Resident 3's rights and resulted in Resident 3 feeling sad.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, one of four sampled residents ' (Resident 3) call light was plugged in and placed within reach, as indicated in the facility ' s policy and procedure (P&P) titled, Answering Call Lights. This failure had the potential for the resident not to call staff for assistance and could delay care and assistance, potentially resulting in falls, pressure ulcers (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence), and neglect.

Inspectors wroteBased on interview, and record review, the facility failed ensure skin treatment orders were not missed on 2/2/2025, 2/13/2025, 2/15/2025, 2/16/2025, 2/17/2025, and 2/18/2025, to one of three residents (Resident 2). This failure had the potential to delay the healing of Resident 2's skin condition and placed the resident at risk for complications.

Inspectors wroteBased on interview, and record review, the facility failed to develop an individualized plan of care for two of two residents (Resident 1 and Resident 2) after a both residents had a physical altercation on 12/22/2024. The deficient practice had the potential for unidentified interventions and placed Resident 1 and Resident 2 at risk for recurring physical altercations, injuries and hospitalization.

Inspectors wroteBased on interview and record review the facility failed to administer one of six sampled resident's (Resident 1) medication as ordered by the physician. This deficient practice placed Resident 1 at risk for subtherapeutic drug levels (level too low to produce intended medical effect of the medication) and worsening of the resident's medical condition or symptoms.

Inspectors wroteBased on observations, interview, and record review, the facility failed to conduct a thorough assessment to one out of three residents (Resident 1), who had a bruise (an injury appearing as an area of discolored skin on the body caused by a blow or impact) on the hand and scratch on arm. This deficient practice caused the facility to not have proper plan of care in place for Resident 1.

Inspectors wroteBased on interview and record, the facility failed to: 1. Re-admit Resident 6 to the facility on [DATE] after the resident discovered the Assisted Living Facility (ALF) did not have an available bed for him. 2. Followed its policy and procedure (P/P) titled Transfer and Discharge, which indicated prior to discharging a resident, the facility will prepare the resident for a safe and orderly discharge and orient the receiving facility of the resident ' s daily patterns. This deficienct practice resulted in Resident 6 staying in a motel for five days, became sick, called 911, and was transferred to a general acute care hospital (GACH) for evaluation and treatment. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the discharge summary for one of three sampled residents (Resident 6), who was discharged to an Assisted Living Facility ([ALF] a residential facility that provides housing and personal care for residents who need help with daily activities but don ' t require the level of care found in a nursing home), was completed with a reconciliation of the resident ' s pre/post discharge medications. This deficient practice had the potential to result in Resident 6 not receiving the needed medications upon discharge and could negatively affect the resident ' s physical well-being.

Inspectors wroteBased on interview and record review failed to: 1. Obtain a doctor order before transering one out of three sampled residents (Resident 2) to the General Acute Care Hospital (GACH). This had the potential to result in adverse outcome, medication error, and/or unnecessary medication or treatment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the shower grab bar (metal bar used as safety devices designed to enable a person to maintain balance or lessen fatigue) in Shower 1, used by 34 of 66 residents , was properly screwed (secured) on the wall. This failure had the potential to cause accidents and injuries.

Inspectors wroteBased on interview and record review, the facility failed to notify, one of three residents ' (Resident 2) family representative and physician after a change in condition (unusual condition) was identified. This failure had the potential for delay in treatment necessary to maintain resident ' s highest practicable mental, physical, and psychosocial well-being.

Inspectors wroteBased on interview, and record review, the facility failed to modify one of three sampled residents' (Resident 2), care plan who had multiple falls, as indicated in the facility's policy and procedure (P&P) titled, Fall Prevention Program, which indicated the facility should implement all precautions to protect the resident and identify approaches to reduce the risk of falls. This failure resulted to a total of five falls (8/29/2023, 3/29/2024, 5/4/2024, 6/30/2024 and 7/19/2024) and placed Resident 2 at risk for further falls and severe injuries which could lead to hospitalization and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Follow physician orders for six out of 18 sampled residents (Residents 7, 9, 37, 39, 42, and 42). These failures had the potential to compromise the residents care and services which could cause medical complications.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure abuse reporting, orientation, and competency assessment post-test (a measurable pattern of knowledge, skills, and abilities) were completed upon hire for four out of five randomly selected staff. This deficient practice had the potential for the facility to not be able to assess nursing skills necessary to assure resident safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure safe and sanitary food preparation practices were being conducted while preparing to serve food in the kitchen. These deficient practices had the potential to result in foodborne illnesses in the highly susceptible resident population.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Inform the physician when one of one sampled residents (Resident 42) continuously refused blood to be drawn for lab test. This deficient practice had the potential to result in a delay of necessary medical care and interventions.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure Resident 15 had a fall mat beside her bed for safety purposes. This deficient practice put Resident 15 at risk for injury in the event of a fall. a. A review of Resident 15's admission Record (Face Sheet) indicated Resident 15 was admitted to the facility on [DATE]. Resident 15's diagnoses included knee pain, muscle wasting, anxiety (excessive worry), and dementia (loss of ability to reason and remember). A review of Resident 15's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 5/10/2024, indicated Resident 15 needed substantial assistance transferring from bed to chair. A review of Resident 15's Physician Orders, dated June 2024, indicated Resident 15 was to have a fall mat on the right side of the bed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure respiratory care was consistent with professional standards of practice when there was no physician order to administer oxygen for one of six sampled residents (Resident 16). This deficient practice had the potential to result in unsafe use of oxygen equipment.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Obtain physician orders for pain for one of 6 sampled residents (Resident 40). This deficient practice had the potential to negatively affect the residents physical comfort and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure an opened personal beverage (soda) of the licensed staff was not stored in the medication cart at Station 1. This failure resulted in a lack of oversight for checking medications stored in medication cart.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Follow its policy and procedure for hospice care (a comprehensive set of services identified and coordinated by an interdisciplinary group ([IDT] team members from different disciplines who come together to discuss resident care) to provide for the physical, psychosocial, spiritual, and emotional needs of a terminally ill patient as delineated in a specific patient plan of care) by failing to ensure hospice representative participates with facility IDT care conference for one of one sampled resident (Resident 42). This deficient practice had the potential to result in a delay or lack of coordination of care and services for residents.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Complete the McGeer Criteria ( minimum set of signs and symptoms which, when met, indicate that a resident likely has an infection and that an antibiotic might be needed) Surveillance Data Collection Form for one of one sampled resident (Resident 173). This deficient practice had the potential to result in the improper use of antibiotics (a drug used to treat infections caused by bacteria).

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure 23 out of 25 resident rooms provided 80 sqft (unit of measure) of living space per resident. This deficient practice affected 23 residents' health and safety, by causing insufficient space for the resident to move around comfortably in his/her room, and did not provide adequate space to easily access furniture.

Inspectors wroteBased on interview and record review, the facility failed to identify resident's needs, and ensure the needed care and services during showers and personal hygiene were provided in accordance with professional standards of practice, and the comprehensive person-centered care plan, for one of three residents (Resident 1). This deficient practice resulted in lice (tiny insects that crawl on the scalp eating human blood) grown in Resident 1's head/ hair that can affect resident's highest practicable physical, mental, and psychosocial well-being. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement one of three sampled residents (Resident 1's) care plan by not monitoring his hypersexual behavior (urges or behaviors that can not be controlled). This deficient practice had the potential to place residents at risk for unwarranted sexual advances.

Inspectors wroteBased on interview and record review the facility failed to complete Physician Orders for Life-Sustaining Treatments (POLST-care directives during life threatening situations) an approach to improve end of life care by encouraging providers to speak with patients and create specific medical orders to be honored by health care workers during medical crisis for five out of six Residents (Residents 11, 49, 8 ,60, and 47). This deficient practice had the potential to delay emergency treatment or the potential to force emergency, life-sustaining procedures against the resident's personal preferences.

Inspectors wroteBased on observation and interview the facility failed to ensure the call lights were within reach for two out five Residents (Resident 6 and 49). This deficient practice placed Resident 6 and 49 at risk for not receiving prompt care when needing assistance.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled resident (Resident 62) were appropriately notified regarding changes in their Medicare coverage through provision of Notice of Medicare Non-Coverage (NOMNC) form. This deficient practice had the potential to result in the responsible parties not being able to exercise their right to file an appeal.

Inspectors wroteBased on interview and record review, the facility failed to ensure the quarterly Minimum Data Set ([MDS] resident assessment and care screening tool) for one of one sampled resident (Resident 7) were completed and submitted within the required timeframe. This deficient practice could potentially affect the care services of Resident 7.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide accurate information in the Minimum Data Set ([MDS] resident assessment and care screening tool) for one of one sampled resident (Resident 2). This deficient practice had the potential to result inaccurate care and services for the Resident 2 due to inappropriate MDS care screening and assessment tool practices.

Inspectors wroteBased on interview and record review the facility failed to ensure one out of five Residents (Resident49) had a revised care plan. This deficient practice of not revising the care plan for Resident 49 had the potential of not receiving appropriate interventions.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, for one of one sampled resident (Resident 19) by failing to notify physician of left foot edema (swelling caused by too much fluid trapped in the body's tissues) and to provide and implement interventions. This deficient practice had the potential to result in a delay in reducing the swelling of the affected extremity and assessing for possible complications.

Inspectors wroteBased on observation, interview and record review, the facility failed to have a sitter monitoring one out of six Residents (Resident 49) 24 hours a day due to impulsive outburst (without warning) behaviors and falls. This deficient practice of not having continuous supervision ([one to one sitter] staff that are immediately at hand to prevent a fall or redirect a patient from engaging in a harmful act) placed Resident 49 at for avoidable injuries.

Inspectors wroteBased on interview and record review, the facility failed to ensure a competency assessment skill (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics in performing that an individual need to perform work roles or occupational functions successfully) checks were performed annually for two of five randomly selected staff. This deficient practice had the potential for the facility not be able to assess the skills necessary to provide nursing services to assure resident safety and to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident will not be performed within the acceptable standards of practice.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide at least 80 square feet (sq. ft.) per resident in multiple resident bedrooms for 23 out of 25 resident rooms. The insufficient space could lead to inadequate nursing care to the residents.