Inglewood Health Care Center

Inspectors wroteBased on interview and record review, the facility failed to follow its grievance process for one of three sampled residents (Resident 1) by failing to:Provide written notification of the grievance investigation results and actions taken. Ensure grievance reports were signed. Make the reports available to the resident or the resident's representative. These failures had the potential to result in delayed communication of grievance outcomes, prevent the resident or resident representative from determining whether concerns were adequately investigated and resolved, and impede the residents ability to exercise their right to appeal, request further review, or pursue additional actions regarding unresolved concerns and impact resident well-being. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of three sampled residents (Resident 1) who refused the covid vaccine and the facility failed to reassess the resident's vaccination status or offer vaccination again during a facility-wide COVID-19 outbreak. This failure had the potential to compromise the resident's health, safety and wellbeing. During a review of Resident 1' s Resident Face Sheet, the Resident Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide treatment, care, and documentation in accordance with accepted professional standards of practice for one of three sampled residents (Resident 1) by failing to:1. Respond to a Certified Nursing Assistant's (CNA's) written report of a change in condition for Resident 1, communicated through the facility's Stop and Watch process (a process whereby CNAs alert licensed staff via a form in writing of a resident's change in condition). Specifically, the Licensed Vocational Nurse (LVN) did not utilize the facility's Stop and Watch communication tool after it was presented by the CNA, delaying appropriate nursing evaluation of the reported change in condition.2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement their policy and procedure (P/P) titled, Medication Administration General Guidelines which indicated to identify residents using at least two resident identifiers by checking the identification band (patient identification bracelet), checking the photograph attached to medical record and/or verifying resident identification with other nursing care center personnel before administering medication, for one of four sampled residents (Resident 1). This failure had the potential to cause medication errors, allergic reactions and life-threatening consequences for Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was provided timely transportation to a dialysis (a type of treatment that helps to remove extra fluid and waste products from your blood when the kidneys cannot) treatment appointment. This deficient practice caused Resident 1 to be late for his dialysis treatment which caused a shortened and incomplete dialysis treatment, placing Resident 1 at risk for a decline in his medical condition.

Inspectors wroteBased on observation, interview and record review, the facility failed to meet professional standards of quality for 2 of 6 sampled residents, Resident 1 and Resident 5, by failing to ensure:1). Scheduled medications were administered in a timely manner in accordance to their physician's order.2). Medications were not left at Resident 1's bedside.3). The medication nurse administered and observe Resident 1 swallowed her medications. These failures had the potential to decrease the drug's therapeutic levels when given late, the potential for Resident 1 not taking her scheduled medications and for other residents to take Resident 1's medications out from her bedside and drink it, causing harm and severe drug interactions.

Inspectors wroteBased on interview and record review, the facility failed to develop a discharge care plan for one of three sampled residents (Resident 3). This deficient practice had the potential to place Resident 3 at risk for an unsafe discharge with poor outcomes such as medication errors, missed follow-up appointments and lack of necessary home care support.

Inspectors wroteBased on interview and record review, the facility failed to report the resident to resident allegations of abuse for the three (3) of 7 sampled residents, (Residents 1, 2 and 3), as indicated in its policy and procedure (P&P) titled, Abuse Prevention Program, when:1). On 3/31/2026, Resident 2 scratched Resident 1 while Resident 1 was entering the dining room. Resident 1 sustained wound on the chin measuring 1 X 0.2 (unit of measurement not indicated) and to the upper lip measuring 0.2 (unit of measurement not indicated) with minimal blood noted.2). On 3/10/2026, Resident 3 slapped Resident 2 who was sitting in a chair, in the hallway.3). On 3/10/2026, Resident 3 was hitting residents and staff.4). On 3/14/2026, Resident 3 swung purse at Resident 1.5). On 3/25/2026, Resident 3 hit Resident 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to report to the California Department of Public Health (CDPH), the verbal altercation (a noisy, angry dispute) on 2/3/2026, between the Social Services Director (SSD) and one of three residents' (Resident 1). This deficient practice delayed the investigation by the CDPH and placed Resident 1 at risk for verbal abuse.

Inspectors wroteBased on interview and record review, the facility failed to investigate the Social Services Director (SSD) and one of three residents' (Resident 1) verbal altercation (a noisy, angry dispute) on 2/3/2026, as indicated in the facility's policy and procedure (P&P) titled Abuse Investigation & Reporting. This deficient practice placed Resident 1 at risk for verbal abuse (the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, within their hearing distance regardless of their age, ability to comprehend or disability) and psychosocial harm.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Social Services Director (SSD) acted in accordance with the professional standards when interacting to one of three sampled residents, (Resident 1). This failure had the potential to affect the resident's psychosocial well-being, leading to emotional harm.

Inspectors wroteBased on interview and record review, the facility failed to honor one of two residents (Resident 1) request, not to have a male Certified Nurse Assistant (CNA) assigned to provide care for activities of daily living (ADLs -routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). This deficient practice violated resident's rights and had the potential to affect the resident's psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to report Influenza A (viral infection that attacks the respiratory system, including the nose, throat, and lungs) outbreak on 2/2/2026, for two of eight residents (Residents 1 and 8), to the California Department of Public Health (CDPH) within 24 hours, as indicated in the facility's policy and procedure (P&P) titled Unusual Occurrence Reporting. This failure resulted in delayed investigation by the CDPH.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Nurse Practitioner's (NP) verbal order of Tamiflu (medication to treat the Influenza [viral infection that attacks the respiratory system, including the nose, throat, and lungs]) for one of three residents (Resident 1), was transcribed to a telephone order form, the Medication Administration Record (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) and notify the pharmacy, as indicated in the facility's policy and procedure titled Physician Orders. This failure resulted in Resident 1 missing two doses of Tamiflu on 2/2/2026 and 2/3/2026.

Inspectors wroteBased on interview and record review the facility failed to ensure one out of five sampled residents (Resident 1) was free from abuse when a Certified Nurse Assistant (CNA 1) kicked Resident 1's right shin (the front of the leg below the knee). This deficient practice resulted in Resident 1 sustaining pain and a purplish discoloration to the right shin. This deficient practice had to potential to cause Resident 1 to not feel safe in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure for one of three sampled residents (Resident 1), who was assessed as being at risk (likelihood) for elopement (leaving the facility unsupervised) and wandering (walking/ travelling from place to place, without any clear aim or purpose) out of the facility and being high risk for falls with a history of multiple falls, was monitored and whereabouts (location in the facility) checked. [...]

Inspectors wroteBased on interview and record review, the facility failed to:1. Maintain the COVID vaccination status for 19 employees. This deficient practice had to the potential to cause a delay in response in the event of an outbreak, since the unvaccinated staff cannot be easily identified. During a concurrent interview and record review on 12/4/2025 at 8:00 a.m. with the Infection Prevention Nurse (IPN), a binder titled Staff Vaccination 2025 was reviewed. The binder indicated 19 employees declined to receive a COVID vaccine. The IPN stated she cannot show documentation of what staff are vaccinated. The IPN stated she is supposed to offer the vaccine to all staff. The IPN further stated it is important to know who is or is not vaccinated in case there is an outbreak. It will be easier to track where the outbreak may have started if you know who is not vaccinated. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe, clean, and sanitary environment when an air filter in the hallway for four of four sampled Residents (Residents 13, Resident 33, Resident 67, and Resident 99) was full of dust and gray, fuzzy substance accumulation. This deficient practice had the potential to exposing residents to an environment that was unclean, and negatively impacting residents' comfort, safety, and quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to:1. Ensure linen was folded using proper technique to prevent recontamination. This deficient practice put residents at risk of infection if they came in contact with the contaminated linen.2. Ensure the Laundry Aide did not pour a chemical into a new unlabeled/uncovered container in the laundry room.3. Ensure air purifier filter in the hallway was maintained in a clean condition for four of four sampled Residents (Residents 13, Resident 33, Resident 67, and Resident 99) when the air filter was full of dust and fuzzy, grey buildup accumulation. This deficient practice had the potential to increase the risk of airborne particle (tiny solid or liquid particles in the air) accumulation in the hallway, which could contribute to the spread of infection among residents.4. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure two of five sampled residents (Resident 78 and Resident 98) was provided with goods and services when1. Resident 98 had notified staff he would like to retrieve his vehicle.2. Staff were standing over Resident 78 while assisting with eating lunch. These deficient practices of not providing goods and services for Resident 98 to escort him to retrieve his vehicle had the potential for him to feel unacknowledged of his needs and placed Resident 78 at increased risk for choking, aspiration, or inadequate monitoring of the resident's tolerance during meals.1. During a review of Resident 98's admission Record ([Face Sheet] front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 98 was initially admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of five sampled residents (Resident 98) walking cane was located when Resident 98 notified Social Worker Director (SSD) the walking cane was missing. This deficient practice of not promptly resolving Resident 98's grievance of the missing walking cane had the potential for Resident 98 to feel the SSD did not want to help him replace the walking cane. During a review of Resident 98's admission Record ([Face Sheet] front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 98 was initially admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure one of five sampled residents (Resident 10) Minimum Data Set ([MDS] a resident assessment tool) was filled out accurately. This deficient practice of not accurately completing the MDS had the potential for Resident 10 goods and services not to be met while residing at the facility. During a review of Resident 10 's admission Record ([Face Sheet] front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 10 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR- a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) was completed for one of one resident (Resident 2). This failure had the potential to result in an inappropriate placement and delay in needed services for Resident 2.

Inspectors wroteBased on observation and interview, the facility failed to ensure one of five sample residents (Resident 4) meal tray was properly set up with containers unopened and within reach for Resident 4 to eat breakfast. This deficient practice of not setting up Resident 4's meal tray had the potential for delay in Resident 4's ability to eat his food and placed him at risk for inadequate nutrition and compromised dignity.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure two of two residents (Resident 18 and Resident 52) was supervised by staff while smoking. This failure had the potential to result to resident injury.

Inspectors wroteBased on observation and interview, the facility failed to ensure one of one resident's (Resident 8) oxygen tubing was labeled with the date the tubing was last changed. This failure had the potential for Resident 8 to receive oxygen through compromised oxygen tubing and increasing the risk of infection while receiving oxygen therapy.

Inspectors wroteBased on interview and record review the facility failed to ensure one of five sampled residents (Resident 57) was monitored for pain. This deficient practice of not monitoring for pain had to potential for Resident 57 to have discomfort. During a review of Resident 57's admission Record ([Face Sheet] front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 57 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 57's diagnoses included conversion disorder with motor deficit (a condition where psychological distress manifests as real, physical systems affecting movement), headache (pain in the head), and encephalopathy (a general brain disorder from injury, disease toxins, or metabolic issues, causing altered brain function). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one resident (Resident 108) had a hemodialysis (HD - a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidneys have failed) emergency kit (e-kit) at bedside. This failure had the potential to result in a delayed emergency interventions during a life-threatening dialysis complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of three sampled Residents (Resident 7, Resident 48, and Resident 111) opened medication boxes and a medication bottle were labeled with the date opened. This failure had the potential to result in the use of medications past their stability period, reducing efficacy and compromising resident's health and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure chocolate frosting, flour, and starch stored in the kitchen were not expired. This failure had the potential to result in unsafe food preparation practices and increased risk of residents consuming foods made with expired ingredients, leading to decreased food quality or foodborne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a television in a safe and operating condition for one of 42 resident rooms' (room [ROOM NUMBER]B), when an uncovered and unsecured cable electrical wire was hanging underneath the television and not having a system in place to timely take care of equipment repairs. This deficiency had the potential to cause injury from electrical hazards.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of five sampled residents (Resident 23) the licensed staff had turned off the oxygen when Resident 23 was not in the room and not in use. This deficient practice of not turning off the oxygen while the resident was not in the room had the potential for hazardous conditions. During a review of Resident 23's admission Record ([Face Sheet] front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 23 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe dietary services were provided to 88 of 93 residents who were served food from the kitchen, when:1. On 8/13/2025, from 5:30 am to 2:25 pm, liquid eggs (processed form of whole eggs, also known as cartoned eggs) were thawed (defrost) at room temperature (ambient temperature [actual temperature] measured by a thermometer around 73 degrees Fahrenheit ([ F]- a unit of temperature) without monitoring the time and temperatures. Liquid eggs were at 55 F which was within the danger zone [41-135 F] temperature range where bacteria grow quickly). 2. On 8/13/2025 from 12:10 p.m. to 1:30 p.m., ground beef was thawed at room temperature without time and temperature monitoring. At 12:10 p.m., the ground beef was at 64 F. At 1:30 p.m., [NAME] 3 placed the ground beef back into the refrigerator (fridge). 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 2) had a functioning television (TV) to watch. This deficient practice resulted in not being able to watch TV clearly when she wanted to.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one out of three sampled residents (Resident 1) resident rights were accommodated when Resident 1 refused a blood draw. This deficient practice of not allowing Resident 1 to refuse blood draw had the potential for the resident to feel discomfort when the staff attempted to draw the blood.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide dental services when one of three residents (Resident 1) did not receive follow up care for partial dentures as requested by the resident. This failure resulted in Resident 1 feeling embarrassed and had the potential to result in the resident having difficulty chewing and eating which could lead to weight loss and aspiration (accidental inhalation of food into the lungs).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled (Resident 3) incontinence brief were changed in a timely manner. This failure had the potential for Resident 3 to develop a skin rash, infection and skin breakdown.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a pain management evaluation for one of three sampled residents (Resident 1). This failure had the potential to result in Resident 1 experience pain that was not controlled.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe, sanitary environment for one of three sampled residents (Resident 3) by not having a soap dispenser in resident ' s bathroom. This failure had the potential to result in the spread of disease and Resident 3 developing an infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure transportation was arranged on 2/11/2025, for 1 of 4 residents, Resident 1, who had a follow up appointment with the Surgeon regarding the Jackson Pratt (a surgical suction drain that gently draws fluid from a wound to help recover after surgery) drain. This failure had the potential to affect the care the resident need post (after) operation, and placed the resident at risk for complications, like infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement infection prevention and control practices during wound care, for 3 of five sampled residents (Residents 2, 3, and 4.) This deficient practice had the potential to cause wound infections and delay wound healing process.

Inspectors wroteBased on interview and record review, the facility failed to recheck the blood pressure, of one of three sampled residents, (Resident 1). Resident 1 had a physician ' s order of no Cardiopulmonary Resuscitation (a procedure to restore normal breathing after cardiac arrest that includes the clearance of air passages to the lungs, mouth-to-mouth method of artificial respiration, and heart massage by the exertion of pressure on the chest) and had a low blood pressure reading. This failure had the potential Resident 1 ' s medical condition not monitored and get worse.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 2), was provided a safe environment when providing wound care. This failure had the potential for Resident 2 to fall and sustain injuries.

Inspectors wroteBased on interview and record review, the facility failed to ensure a competency assessment skills check (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) was performed upon hire and annually for two out of five randomly selected staff. This deficient practice had the potential for the facility to not be able to assess the skills necessary to provide nursing services while assuring resident safety and attaining or maintaining the highest practicable physical, mental, and psychosocial well-being of each resident within the acceptable standards of practice.

Inspectors wroteb. During an interview with Resident 33 on 10/15/2024, at 10:18 a.m., Resident 33 stated she was a vegetarian but the facility serves her meals that include meat dishes. A review of Resident 33's diet order indicated a regular diet, no added salt (NAS), reduced concentrated sweets (RCS), jello with all meals, small portion only, salad for lunch [NAME] at patient's request. During an observation of 10/16/2024, at 12:40 p.m., Resident 33 was served a plate of food with a hamburger bun with a slice of orange cheese and a meat patty on it. During an interview on 10/16/2024, at 11:40 a.m. with Certified Nursing Assistant (CNA) 8, CNA 8 stated she was aware Resident 33 was a vegetarian. [...]

Inspectors wroteBased on observation, interview, record review, the facility failed to ensure safe and proper storage of items in the refrigerator when : 1. One frozen bottled water was found not labelled in the freezer. 2. Undated, opened food items were found in the refrigerator and under the food preparation counter. 3. The internal refrigerator fan which was blowing air over uncovered fresh produce had black substances on the fan blades. These deficient practices of not dating and labelling opened food, improper sanitation of equipment for food storage, and food stored in open containers without covers had the potential for harmful bacteria growth and cross-contamination (transfer of harmful bacteria from one place to another) that could lead to food -borne illness.

Inspectors wroteBased on interview and record review, the facility failed to revise and provide an updated accurate resident census in the Facility's Assessment (a process for evaluating a facility's resident population and identifying the resources needed to provide care and services). This deficient practice had the potential to place residents at risk for delay of care and treatment services.

Inspectors wroteBased on interview, and record review, the facility failed to implement the antibiotic stewardship program (coordinated program that promotes the appropriate use of antibiotics by clinicians) by failing to monitor and address antibiotic (a substance used to kill bacteria or to treat infection) use for one of one sampled resident (Resident 20) who was on antibiotics for urinary tract infection [(UTI) an infection in the bladder/urinary tract] was not evaluated when the resident returned from the hospital. The failure had the potential for Resident 20 to receive an inappropriate antibiotic and develop antibiotic resistance.

Inspectors wroteBased on interview and record review, the facility failed to ensure Certified Nurse Assistant 5 (CNA 5) was not assigned to one out of five sampled residents (Resident 195) after the resident's family member (FM 1) filed a grievance regarding CNA 5's loud and rude behavior. This deficient practice had the potential to affect Resident 195's sense of self-worth and self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to ensure one out of five sampled residents (Resident 81) was notified her missing Electronic Benefit Transfer ([EBT]- to access benefits for food and cash aid) card was found. This deficient practice of not notifying Resident 81 the EBT card was found had the potential to cause distress for Resident 81.

Inspectors wroteBased on interview and record review, the facility failed to ensure one out of five sampled residents (Resident 81) was offered an opportunity to file a grievance (a complaint) for a missing Electronic Benefit Transfer ([EBT]- to access benefits for food and cash aid) card. This deficient practice of not allowing Resident 81 to file a grievance for missing the EBT card had the potential to cause distress for Resident 81.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete the Minimum Data Set ([MDS]- a federally mandated resident assessment tool) Section A for the level II Preadmission Screening and Resident Review ([PASRR] a tool to determine if the person had or was suspected of having a mental illness or intellectual disability) condition for two out of five sampled residents (Resident 42 and 85). This deficient practice resulted in incorrect data transmitted to the Centers for Medicare and Medicaid Services (CMS) and had the potential to result in inaccurate care and services for Resident 42 and 85. Cross Reference F644.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Preadmission Screening and Resident Review ([PASRR] a tool to determine if the person had or was suspected of having a mental illness or intellectual disability) was resubmitted for two out of five sampled residents (Resident 42 and 85). This deficient practice had the potential to result in Residents 42 and 85 not receiving the necessary mental health care and services needed. Cross Reference F641.

Inspectors wroteBased on interview and record review, the facility failed to develop a person-centered care plan for two of five sampled residents (Resident 83 and Resident 195) by failing to: 1. Develop a comprehensive care plan addressing Resident 83's smoking. 2. Develop a care plan after Resident 195 filing of two grievances (a wrong or hardship suffered, real or supposed, which forms legitimate grounds of complaint). These deficient practices had the potential to negatively affect the delivery of necessary care and services for Resident 83 and Resident 195.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one out of six sampled residents (Resident 32) dentures were cleaned daily. This deficient practice of not cleaning Resident 32s dentures daily made Resident 32 feel frustrated.

Inspectors wroteBased on interview and record review, the facility failed to ensure a follow-up cataract (a medical condition in which the lens of the eye becomes cloudy) and glaucoma (group of eye conditions that can cause blindness and gradual loss of sight) appointment was scheduled for one of three sampled residents (Resident 85). This deficient practice had the potential to result in Resident 85's worsening vision that would negatively affect his quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one out of six residents (Resident 84) had the correct low air loss (LAL) mattress (an air mattress with small holes that helps prevent pressure wounds and keeps the skin dry and cool) setting to prevent pressure ulcer development (localized injuries to the skin and soft tissue caused by prolonged pressure on the skin). This deficient practice of not having the correct LAL mattress settings had the potential for Resident 84 to develop a pressure ulcer.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one out of six sampled residents (Resident 32) had the correct diet texture when not wearing dentures. This deficient practice of not providing the correct diet texture had the potential for Resident 32 to not properly chew his food.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sample resident (Resident 83) with post traumatic stress disorder ([PTSD] - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event) received informed trauma care ([TIC] - an intervention and approach that focuses on how trauma may affect an individual's life and his or her response to behavioral health) per their policy. This deficient practice had the potential for the staff's inability to identify possible triggers that could result in re-traumatization (the reactivation of trauma symptoms via thoughts, memories, or feelings related to the past traumatic experience) for Resident 83. Cross Reference F745.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the staff was following the physician orders for the correct oxygen settings for one out five sampled Residents (Resident 12). This deficient practice of not following the physician orders had the potential to worsen Resident 12's health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was provided with medically related social services and emotional support while grieving for one of one sampled resident (Resident 83). This deficient practice placed Resident 83 at risk for further depression (a serious mental illness that can affect how a person feels, thinks, and acts) and ineffective coping ability.

Inspectors wroteBased on interview and record review, the facility failed to ensure a pharmacy consultant (a professional responsible for reviewing each resident's medication profile monthly to identify and report changes) recommendation to consider a trial reduction of psychotropic medication (drug that affects behavior, mood, thoughts, or perception) was acknowledged and acted upon for one out of five sampled residents (Resident 83). This deficient practice had the potential to result in Resident 83 receiving unnecessary medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an opened multi-dose tuberculin (a sterile liquid that contains substances taken from the bacterium that causes tuberculosis and is used in the diagnosis of the disease) vial was labeled with an expiration date in the medication storage room. This deficient practice had the potential to result in a medication error and/or administering expired medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the oxygen humidifier (a device that adds moisture to prevent dryness) was dated and labeled for one out of five sampled residents (Resident 12). This deficient practice of not dating and labeling the oxygen humidifier had the potential to cause respiratory infection to Resident 12.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Care Plan for two of four sampled residents (Resident 1 and Resident 3) who were at risk for fall, were revised and individualized to include the level of staff assistance needed for the safe transfer and mobility (ability to move) of the residents. This deficient practice had the potential to result in unidentified nursing interventions and recurrent falls for Residents 1 and 3.

Inspectors wroteBased on interview and record review, the facility failed to provide needed assistance for one of four sampled Residents (Resident 3), who was assessed as needing partial/moderate assistance (resident could perform half of the mobility task while staff assisted with 50%) after toileting and while ambulating (walking). This failure resulted in Resident 3 sustaining a fall and placed the resident at risk for injuries and hospitalization from a fall.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 2) was free from physical abuse by Resident 1 by failing to: 1. Follow Resident 2 ' s Care Plan and physician ' s order to monitor and address episodes of aggressive and abusive behaviors. 2. Revise and individualize (tailoring to the resident) the Care Plan for Resident 2 who had a history of altercations and aggressive behaviors. 3. Ensure Residents 1 and 2 who had prior resident-to resident altercation on 7/29/2024, were separated. 4. Follow the facility ' s Policy and Procedure titled, Abuse Prevention Program which indicates the facility would protect residents from abuse. [...]

Inspectors wroteBased on interview and record reviews, the facility failed to: 1. Follow their policy and procedure (P&P) titled, Resident Elopement (an instance of a patient or person in care leaving a care facility, or safe area independently without notifying anyone), which indicated, the facility will provide a safe environment and preventive measures for elopement. 2. Follow their policy and procedure (P&P) titled, Safety Supervision of Residents, which indicated, resident supervision is a core component of the systems approach to safety. As a result, one of three resdients, Resident 1, left the facility unsupervised.

Inspectors wroteBased on interview and record review, the facility failed to obtain a physician order to allow 1 of 5 sampled residents (Resident 1), to leave the facility on out on pass . This failure had the potential to jeoaprdize resident's safety and may result to bodily injuries.

Inspectors wroteBased on interview and record review, the facility failed to ensure medication was administered as ordered, for one of three sampled residents (Resident 1). This deficient practice had the potential to a poor healing process of Resident 1 ' s vaginal condition.

Inspectors wroteBased on interview and record review, the facility failed to implement its infection prevention and control policy and procedure (P&P) by failing to report the facility ' s Coronavirus ([Covid-19] a highly contagious infection caused by a virus that could easily spread from person to person) outbreak (at least one confirmed case of Covid-19 who had resided for at least 7 days in the facility) to the California Department of Public Health (CDPH) District Office (DO). This deficient practice had the potential to result in a delay in the investigation by the DO and the spread of Covid-19.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow physician orders and care plan interventions by ensuring the nursing staff turned on a wheelchair pad alarm (a weight-sensitive sensor pad that is connected to a monitor unit and activates an alarm if a resident leaves the chair or the bed) to ensure its working properly and alerts staff of a potential fall for one of three sampled residents, (Resident 2). This failure had the potential to increase Resident 2 ' s risk of falling and sustaining injuries.

Inspectors wroteBased on interview and record review, the facility failed to ensure eight of 20 sampled residents' (Residents 18, 35, 3, 25, 41, 45, 53 and 72) medical records were updated to show documentation that advance directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes were carried out should the person be unable to communicate them to a doctor) were discussed and written information provided to the residents and/or their responsible parties. This deficient practice violated the residents' and/or the responsible parties' rights to be fully informed of the option to formulate their advance directives and had the potential to cause conflict with the residents' health care wishes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure the Lorazepam oral solution (a medication used to treat mental illness) was stored in one of one inspected medication rooms, (Station 1 Medication Room), and ensure the 29.5 milliliters (ml - a unit of measure for volume) of lorazepam was accounted for and was maintained for Resident 60's use. 2. Reorder Lactulose solution (a medication used to maintain regular bowel movements) for one of three residents (Resident 1), from the facility's contracted pharmacy, to ensure the medication supply was available between 6/13/2023 and 10/26/2023 and was available during the observed medication administration for Resident 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the licensed staff checked the expiration date of Humalog insulin (a medication used to treat high blood sugar) before administering 36 doses between 10/14/23 and 10/25/2023 to one randomly observed resident (Resident 61.) (cross-refer F761) The deficient practice of failing to check the expiration date of insulin prior to administration increased the risk that Resident 61 could have experience medical complications such as poor blood sugar control or injection site infections which may have resulted in hospitalization and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure licensed staff did not falsify the Medication Administration Record (MAR - the record of all medications administered to a resident) by documenting the administration of lactulose (a medication used to maintain regular bowel movements) 267 times when the product was unavailable in the facility between 6/13/23 and 10/26/2023, for one of three residents observed for medication administration (Resident 1). (cross-refer F755) The deficient practice of failing to ensure the medical records accurately reflect care delivered to the resident increased the risk that Resident 1 may not have received her lactulose as ordered and may have received unnecessary dosage adjustments possibly resulting in medical complications leading to an overall diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to assist and document grievance for missing personal clothing for one of one sampled resident (Resident 57). This deficient practice violated the resident's right to have his grievance addressed.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS), a standardized assessment and care screening tool, for Significant Change in Status Assessment (SCSA), is a comprehensive assessment that must be completed when the Interdisciplinary Team (IDT) has determined that a resident meets the significant change guidelines for either improvement or decline, was completed within the time frame for one of one sampled resident (Resident 25). This deficient practice had the potential to result inaccurate care and services due to inappropriate MDS care screening and assessment tool practices.

Inspectors wroteBased on interview, and record review, the facility failed to correctly fill out the Preadmission Screening and Resident Review (PASRR, a tool to determine if the person had, or was suspected of having, a mental illness, intellectual disability, or related condition) level one screening and refer one of three sampled residents (Resident 15) who had a diagnosis of schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves) to the appropriate state-designated authority for PASRR level two evaluation and determination. This failure had the potential to result in Resident 15 not receiving appropriate treatment recommendations for schizophrenia.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan for physical therapy (the treatment of disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise rather than by drugs or surgery) and occupational therapy (a form of therapy for those recuperating from physical or mental illness that encourages rehabilitation through the performance of activities required in daily life) for one of one sampled resident (Resident 25). This deficient practice had the potential to negatively affect the delivery of care and services to Resident 25.

Inspectors wroteBased on interview and record review, the facility failed to update and revise a comprehensive care plan to include the new physician's order for wound care treatment for one of one sampled resident (Resident 33). This deficient practice had the potential to place Resident 33 to not receive appropriate care and/or services.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of six sampled residents (Resident 18), who was assessed at risk for weight loss received High Protein Nutrition (HPN) as indicated in the physician orders and nutritional assessment. This deficient practice had the potential for further weight loss to Resident 18 by not providing the HPN as ordered.

Inspectors wroteBased on interview and record review, the facility failed to act on one recommendation from the pharmacy consultant (a professional responsible for reviewing each resident's medication profile monthly to identify and report changes) from September 2023 for routine lab works, the Complete Metabolic Panel (CMP) (a test that measures different substances in the blood, and provides important information of your body's chemical balance and how it uses food and energy), Complete Blood Count (CBC) (a blood test used to look at overall health conditions and blood disorders), lipid panel (a blood test used to monitor and screen your risk for heart disease), Hemoglobin A1c (HBA1c) (average level of blood sugar over the past two to three months) and magnesium levels (a test measuring the amount of mineral you get from foods you eat for high or low levels), in one of five sampled residents, [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to discard a bottle of Humalog insulin (a fast-acting medication used to treat high blood sugar) with an opened date of 9/16/23 according to the manufacturer's requirements affecting Resident 61 in one of two medication carts inspected (Station 2 Medication Cart). (cross-refer F760) The deficient practice of failing to discard opened bottle of Humalog insulin within the date recommended by manufacturer resulted in Resident 61 received 36 doses between 10/14/23 and 10/25/23 per medication administration record (MAR) (important information about someone's medication, time, date, and amount taking).

Inspectors wroteBased on interview and record review, the facility failed to document and provide education regarding the benefits and risks of immunization and administration of influenza (a contagious respiratory illness) vaccine and pneumonia ([PNA] infection of the lungs) vaccine (medication to prevent a particular disease) to residents or resident's responsible party for four of five sampled residents (Residents 13, 18, 38, and 80). This deficient practice resulted in incomplete resident's medical records.