Intercommunity Care Center

Inspectors wroteBased on interview and record review, for one of six sampled residents (Resident 130), the facility failed to: provide non-pharmacologic interventions prior to administering psychotropic medications: Zyprexa [medication used to treat schizophrenia (a mental illness that is characterized by disturbances in thought) or bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs)] and Remeron (medication used to treat major depressive disorder) Monitor resident for the specific manifested behaviors for the use of Remeron. This deficient practice had the potential to place residents at risk for receiving unnecessary medication.

Inspectors wroteBased on interview and record review, the facility failed to ensure the quarterly Minimum Data Sets (MDS- a resident assessment tool) were completed within the required time frame for five of five sampled residents (Residents 21, 34, 123, 12, and 88) as evidenced by:A. Failing to assess and transmit the required quarterly MDS for Residents 21,34, and 123 within the mandated OBRA assessment (a federally mandated evaluation required for every resident in a Medicare or Medicaid-certified nursing facility, regardless of how they pay for their care) schedule (every 92 days). B. Failing to complete quarterly MDS for Residents 12 and 88 timely. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive, person centered care plan for four of ten sampled residents (Resident 59, 115, 13, and 80) related to:A. Failing to reflect, develop, and implement a comprehensive, person centered care plan that addressed Resident 59's post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event) triggers with specific, individualized interventions and Resident 115's skin excoriation (a scrape or scratch to the skin) from scratching with untrimmed fingernails. B. Complete a quarterly joint mobility assessment (JMA, assessment of joint range of motion [ROM, full movement potential in a joint] to monitor changes) since 7/4/2024 in accordance with Resident 80's care plan. C. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from potential accidents when:1. The facility did not ensure Resident 122 was reevaluated by physical therapy when Resident 122 started to pull their front wheel walker (FWW - type of mobility aid with wide base of support) behind them when walking instead of pushing the FWW in front of their body.2. The facility failed to ensure an electrical panel (the central hub that distributes electricity from the grid into the facility) was secured and not easily accessible to ambulatory residents affecting 78 out 141 residents. 3. One out of one sampled residents (Resident 112) was observed being pushed in the hallway while sitting on a rollator walker (a wheeled mobility aid). 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure [NAME] nursing staff was competent when:1. A new physician's order was not carried out for one of eight sampled residents (Resident 40) 2. Checking residents trays, when Licensed Vocational Nurse (LVN) 7 did not know how to identify residents' ordered diet texture using the facility's color coded diet system affecting 46 of 141 residents on a texture modified diet such as pureed (paste or thick liquid suspension made from finely ground cooked food) or mechanical soft diet (diet for residents who experience chewing or swallowing limitations, food texture is modified by chopping or grinding). These deficient practices had the potential for a delay in care for Resident 40 and facility residents to receive the wrong food texture resulting in malnutrition or choking. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%). Three medication errors of 31 total opportunities contributed to an overall medication error rate of 9.68 % affecting two of four residents observed for medication administration (Resident 81 and Resident 146). The medication errors noted were as follows:1. Resident 81's prescribed metformin hydrochloride (medication used to control the amount of sugar in the blood) was not administered as ordered at the scheduled time.2. Resident 146's midodrine (medication used to increase blood pressure [[force of blood pushing against the blood vessels walls in the heart]) and esomeprazole (medication used to prevent production of too much acid in the stomach) were not available for administration as ordered by the physician. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure:1. Resident 50's Humulin R (regular insulin - medication used to lower blood sugar levels) with open date labeled 4/30/2026 was discarded.2. Acidophilus (a supplement used to keep digestive system healthy) opened on 6/4/2026 was stored in the refrigerator according to manufacturer's guidelines.3. Resident 64's used Lantus Solostar (Insulin Glargine - a long-acting insulin used to control blood sugar levels throughout the day and night) was labeled with date opened.4. Resident 7's unused Lantus Solostar was refrigerated as indicated on the pharmacy label. These failures had the potential to compromise the integrity and effectiveness of the medications, placing residents at risk for adverse drug side effects and ineffective treatment.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the facility's diet menu instructions when preparing food for 31 of 141 residents on mechanical soft diet (diet for residents who experience chewing or swallowing limitations, food texture is modified by chopping or grinding). This deficient practice had the potential to increase the residents' risk for aspiration (inhalation of foreign materials) or choking.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure:One container of shredded coconut labeled 2/2/2025 was disposed ofThe ice machine was free of dirt. These deficient practices had the potential to place the residents at risk for food borne illness or cross-contamination (the unintentional transfer of harmful bacteria, viruses, or allergens from one surface, object, or food to another).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Certified Nurse Assistant (CNA) 4 spoke to one of seven sampled residents (Resident 119) in a respectful manner. This failure had the potential for Resident 119 to experience loss of dignity and decreased self esteem.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of six sampled residents (Resident 130)'s: informed consent for Zyprexa [medication used to treat schizophrenia (a mental illness that is characterized by disturbances in thought) or bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs)] included the manifested behavior for the medication indication useInformed consent for Remeron (medication used to treat major depressive disorder) was renewed every six months. This deficient practice had the potential to violate the residents' right to make an informed decision regarding the use of psychotropic medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor and accommodate the resident's food preferences in a timely manner for one of four sampled residents (Resident 106). This deficient practice had the potential to negatively impact the resident's nutritional status, appetite, autonomy, and overall well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete a change of condition and notify the physician when:a. one of 28 sampled residents (Resident 80) had a significant change in physical status identified in 4/2026 when multiple Restorative Nursing Aide (RNA, nursing aide program that help residents to maintain their function and joint mobility) staff reported Resident 80's repeated refusals to wear splints (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) and attempts to take off splints.b. Resident 122 started to pull their front wheel walker (FWW - type of mobility aid with wide base of support) behind them when walking instead of pushing the FWW in front of their body. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three out of three sampled residents (Resident 150, Resident 160, and Resident 170) were provided privacy when Resident 144 was observed going into their room and using the restroom without permission. This deficient practice had the potential to violate the resident's rights and right to privacy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, comfortable, and homelike environment when the facility failed to:1. Provide Resident 12 with a pillow. 2. Provide Resident 88 with a pillow. 3. Ensure one out of 8 sampled residents (Resident 100) did not have peeling paint in their restroom. These deficient practices placed Residents 12, 88, and 100 at risk of not experiencing the facility as their home, and placed Residents 12 and 88 at risk of discomfort while resting in bed

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of three sampled residents (Resident 146) by failing to: Ensure there was an informed consent form prior to the abdominal binder (a soft band made of stretchy soft material that wraps around the stomach). being on Resident 146. Completed a physical restraint assessment. Initiated an abdominal binder care plan. Monitor the use of an abdominal binder. These deficient practices had the potential to result in injury and inhibit the residents' freedom of movement or activity. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's fingernails were kept trimmed and clean to prevent skin excoriation (a scrape or scratch to the skin) caused by scratching for one of seven sampled residents (Resident 115). This failure had the potential to result in further skin injuries and infection for Resident 115.

Inspectors wroteBased on observation, interview, and record review the facility failed to monitor one of three sampled resident's (Resident 40) eyes as ordered by the physician. This deficient practice had the potential for a delay of care to occur for Resident 40.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services and treatments to maintain or prevent further decline in joint range of motion (ROM, full movement potential in a joint) in two of 28 sampled residents (Residents 80 and 36) when the facility failed to:1. Provide Resident 80 Physical Therapy (PT, a rehabilitation profession that restores, maintains, and promotes optimal physical function) treatments to assess and establish a safe wear time for new ankle splints (rigid material or apparatus used to support and immobilize a broken bone or impaired joint).2a. Objectively measure Resident 36's ROM impairments in the left hand during an Occupational Therapy (OT, rehabilitative profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) evaluation dated 12/8/2025.2b. [...]

Inspectors wroteBased on interview, and record review, the facility failed to Identify and to intervene on events in one of three sampled residents (Resident 59)' history of trauma and triggers which may cause re-traumatization (a person encounters a new event or stimulus that triggers them to re-experience the intense stress, emotional distress, and even flashbacks of a previous traumatic event as if it were happening again). This failure had the potential to result in Resident 59 experiencing re-traumatization, and a declining quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of five Certified Nursing Assistants (CNA) had an annual performance evaluation. This failure had the potential to result in staff performing duties without adequate assessment of their competency, knowledge, and job performance leading to errors in resident care, failure to identify training needs, and decreased quality of care.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure one of four sampled residents (Resident 146)'s prescribed midodrine (medication used to treat low blood pressure) was available to administer, after the last dose was administered on 6/7/2026. This failure resulted in Resident 146 not receiving the prescribed midodrine and had the potential to result in delayed treatment of hypotension (low blood pressure), decreased perfusion (blood flow) to vital organs, and the need for additional medical interventions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four residents (Resident 146) was free from significant medication error (any preventable error in medication administration that can result in resident discomfort, jeopardizing health and safety, or requiring medical intervention) by failing to:1. Ensure the physician was notified when Resident 146's prescribed midodrine (medication used to treat low blood pressure) was unavailable for administration 2. Ensure the physician was notified when Resident 146 subsequently experienced an episode of low blood pressure. This failure resulted in a significant medication error by not administering the medication as ordered by the physician and had the potential for Resident 146's increased risk for adverse effects of low blood pressure.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain accurate and complete medical records for two of 28 sampled residents (Resident 36 and 146) when the facility failed to:1. Sign Resident 36's Joint Mobility Assessments (JMA, assessment of joint range of motion [ROM, full movement potential of a joint] to monitor changes) dated 9/25/2025 and 12/22/2025.2. Ensure accurate medication administration and documentation by signing the Medication Administration Record (MAR) to reflect Resident 146 did not receive the prescribed midodrine (medication used to treat low blood pressure) when the medication was not available and was not administered. These deficient practices resulted in inaccurate and incomplete medical records for Residents 36 and 146.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control measures by not ensuring that the padded side rails and bed frames wrapped with porous (having minute spaces or holes through which liquid or air may pass) foam were properly disinfected for one of seven sampled residents (Resident 49). This failure had the potential to result in compromised infection control measures to prevent the spread of infection among residents, staff, and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its antibiotic stewardship program [the effort to ensure that antibiotics (medicines that fight bacterial infections in people) are used only when necessary and appropriate] for one of three sampled residents (Resident 115) by not identifying the indication and duration of the prescribed antibiotic and not assessing the resident using Loeb's Minimum Criteria (a set of standardized guidelines designed primarily for long-term care facilities to prevent the overuse of antibiotics). This failure had the potential to result in Resident 115 developing antibiotic resistance (the ability of bacteria to change and survive the effects of antibiotics designed to kill or stop them), increasing the risk that Resident 115 could receive unnecessary or inappropriate antibiotic therapy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide two of 28 sampled residents (Residents 12 and 80) with safe resident care equipment when:1. Resident 12's floor mat was torn and did not extend the full length of Resident 12's bed.2. Resident 80's wheelchair armrests were torn, and the padding underneath was exposed and Resident 80's pommel cushion (wheelchair cushion with raised middle portion for positioning) had duct tape taped around the middle raised portion and the foam inside was exposed. These failures had the potential to cause injury if Resident 12 fell off the bed and cause Resident 80 skin irritation and excoriation (scrape or scratch to the skin) when the skin rubbed against the duct tape and torn wheelchair cushion materials.

Inspectors wroteBased on observation, interview and record review, the facility failed to:Develop and implement an individualized fall prevention care plan, for one of three sampled residents (Resident 1) with interventions including reminding the resident to use a front wheeled walker ([FWW] a mobility aid with two wheels on the front legs and rubber-tipped or sliding legs on the back), and calling for assistance before walking. Implement the facility's Policy and Procedure (P&P) titled Care Planning-Interdisciplinary Team ([IDT]- Residents health care team consisting of variousspecialties), which indicated the Resident's IDT was responsible for the development of an individualized comprehensive care plan for each resident. [...]

Inspectors wroteBased on interview and record review, the facility failed to report an injury of unknown origin to the California Department of Public Health (CDPH), when one of three sampled residents (Resident 1) was found on the floor in his room, face down and unresponsive requiring CPR and who subsequently expired at the facility on [DATE] This deficient practice resulted in the CDPH being unaware of Resident 1's injury and the inability of the CDPH to conduct a timely investigation which hindered their efforts to determine the cause of the incident (e.g., fall, assault, or medical event). This deficient practice had the potential for information related to the investigation to be lost and/or forgotten

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the resident received treatment and care in accordance with professional standards of practice for one of three sampled residents (Resident 1) by failing to ensure Certified Nurse Assistant (CNA)1 placed the foot pedals (also known as foot rests- designed to provide postural support and stability as well as distribute weight bearing during sitting or transporting) before transporting Resident 1 to the dining room for lunch via wheelchair. [...]

Inspectors wroteBased on observation. interview and record review, the facility failed to implement infection control measures by failing to: A. Ensure implementing Enhanced Barrier Precaution (EBP- an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities) for Resident 54 who had gastrostomy tube (G-tube-a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) placed. B. Implement the water management plan (comprehensive plan aimed at preventing waterborne illnesses by controlling germs in the water). C. Implement EBP interventions when Licensed Vocational Nurse 1 (LVN) 1 provided direct care for Resident 119. D. Perform hand hygiene between Resident care for Resident 77, Resident 90 and Resident 137. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the protection and promotion of resident rights for two of two sampled residents (Resident 22 and Resident 89) by: a. Not providing eye level positioning while assisting Resident 89 with eating. b. Not ensuring privacy curtain was closed exposing Resident 22's left buttock . These deficient practices resulted in residents not being treated with dignity and respect, and not receiving care in a manner that promotes quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement person centered care plans ( (a document that outlines a resident's care needs, diagnosis, and treatment goals) for five out of five sampled residents (Resident 95,120,396, 93 and 5), by failing to: A.Implement care plan interventions for elopement risk for Resident 95. B.Implement a comprehensive care plan for Resident 120 who had a diagnosis of post-traumatic stress disorder ([PTSD], a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event). C. Develop a baseline smoking care plan for Resident 93, Resident 396, and Resident 5 who smoke. These deficient practices had the potential for the residents' care needs not to be addressed and the lack of ability to identify the residents' ongoing needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow proper sanitation and food handling practices by: 1. Failing to label open bag of pancake mix with an open date. 2. Failing to place a lid on an open container of breadcrumbs 3. Failing to close the lid on macaroni noodles and egg noodles 4.[NAME] to clean stationery can opener when it was found with a black tarry substance on it. These deficient practices had the potential to result in using pancake mix beyond its expiration date causing vulnerable residents to get sick. Pests, dust and other airborne particles that can contaminate the food items, and a potential for food contamination from the tarry substance on the can opener. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure two of five sampled residents' (Resident 91 and 96) pneumococcal vaccination (medication that helps protect against serious illnesses like pneumonia [lung infection]) status was documented in Resident 91 and 96's medical records. This deficient practice had the potential to result in inaccurate depiction of resident health status.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure 160 of 160 facility staff were educated on Enhanced barrier Precautions (EBP - involve gown and glove use during high-contact resident care activities). This deficient practice had the potential to result in increased risk of cross contamination (the physical movement or transfer of harmful germs from one person, object or place to another).

Inspectors wroteBased on interview and record review, the facility failed to obtain a completed psychotropic medication (drugs that are used to treat a variety of mental health conditions) consent (a document that legally and ethically records an individual's agreement to participate in a specific treatment, ensuring they understand the potential risks and benefits involved) for one of six sampled residents (Resident 119). This failure had the potential for escalation of symptoms due to delay or failure initiating needed treatment due to lack of consent and can lead to worsening psychiatric (relating to mental illness) symptoms.

Inspectors wroteBased on observation, interviews, record review, the facility failed to ensure the call light was within reach for one of six sampled residents (Resident 94). This failure had the potential for increased risk of falls, delayed response to emergencies, and unmet basic needs of Resident 94.

Inspectors wroteBased on interview, and record review, the facility failed to implement less restrictive restraints (to limit, restrict, or keep under control) before the use of a Geri-chair (a specialized large, padded chair with wheeled base to enable transport, designed to recline and to assist residents with limited mobility) with a lap tray (a detachable tray that attaches to most chairs) and provide ongoing monitoring for the continued use of the restraint to keep one of two sampled residents from falling (Resident 134). This deficient practice had the potential to place Resident 134 at risk for decline in physical functioning, and potential for unwanted behaviors when there was no monitoring for continued use of the lap tray.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete the minimum data set (MDS - a resident assessment tool) assessment Section I (active diagnoses), dated 3/10/25, by failing to include a diagnosis of schizophrenia (a mental illness characterized by hearing or seeing things that are not there) per information in the medical record for one of five residents sampled for unnecessary medications (Resident 92.) This deficient practice of failing to accurately assess active diagnoses and complete MDS Section I increased the risk that Resident 92 may not have received care planning and treatment according to his needs possibly leading to a decline in his overall health and well-being.

Inspectors wroteBased on interview, and record review, the facility failed to complete the Preadmission Screening and Resident Review (PASARR - resident screening to ensure those with severe mental illness or intellectual disability are receiving services according to their needs) Level 1 for one of three sampled residents (Resident 40) pre admission or soon there after. This deficient practice had the potential to result in an inappropriate placement and delay of the residents' needed services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatments and services to improve, prevent and/or limit a decline in joint (where two bones meet) range of motion (ROM, full movement potential of a joint) to one of eight sampled residents (Resident 109) who was identified as having ROM limitations in the right hand, right wrist, and left ankle. This deficient practice had the potential to cause Resident 109 to have a decline in ROM leading to contractures (loss of motion of a joint associated with stiffness and joint deformity) and have a decline in physical functioning such as the ability to eat, dress, and walk.

Inspectors wroteBased on interview and record review, the facility failed to monitor and document hourly rounds to prevent elopement (an unauthorized departure of a patient from an around-the-clock care setting without the facility's knowledge and supervision) for one of three sampled residents (Resident 95) who was at risk for elopement. This failure had the potential to result in Resident 95 potentially eloping the facility and being put at risk for accidental injury or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 49)'s nasal cannula was labeled with a date to ensure it was changed timely. This failure had the potential to place Resident 49 at risk of infections and health complications due to use of the same nasal cannula for an unknown prolonged period of time

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 120), who was diagnosed with post-traumatic stress disorder ([PTSD], a mental health condition that can develop after someone experiences or witnesses a traumatic event), received trauma informed care (a model that aims to provide effective mental health services by taking into account a person's past experiences with trauma). This deficient practice had the potential to result in Resident 120's re-traumatization and can be detrimental for the resident's psychosocial well being.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff were in-serviced (educated) for post-traumatic stress disorder ([PTSD], a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event) and trauma informed care for one of three sampled residents (Resident 120) who had a diagnosis of PTSD. This deficient practice had the potential to negatively affect all residents that reside in the facility with diagnosis of PTSD due to staff not being aware of and how to care for the residents with PTSD.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%). Two medication errors out of 26 total opportunities contributed to an overall medication error rate of 7.69 % affecting one of four residents observed for medication administration (Resident 21.) The medication errors noted were as follows: 1. Attempted early administration of multivitamin (a vitamin supplement) 2. Attempted early administration of vitamin D (a vitamin supplement) These deficient practices of failing to administer medications in accordance with the physician's orders increased the risk that Resident 21 may have experienced medical complications possibly resulting in hospitalization.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Label one opened vial of Humulin R (a type of insulin used to control blood sugar) with an open date affecting Resident 6 in one of three inspected medication carts (Station A Medication Cart.) 2. Remove one expired vial of Humulin R opened on [DATE] from the medication cart affecting Resident 104 in one of three inspected medication carts (Station A Medication Cart.) These deficient practices of failing to store or label medications per the manufacturers' requirements increased the risk that Residents 6 and 104 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 provide documented evidence of all employees screening, education, offering, and current Corona virus disease, COVID-19 (contagious infectious disease), vaccination (medications used to prevent diseases usually given by injection or by mouth) status. This failure had the potential to place staff and residents at risk for serious outcomes such as being hospitalized due to COVID-19.

Inspectors wroteBased on observation, interview and record review, the facility failed to meet the requirement of no more than four residents per room, when three of the 63 resident Rooms, which included room [ROOM NUMBER], 50, and 61, accommodated more than four residents. This failure had the potential to decrease the residents' privacy, quality of care, quality of life, and negatively affect the delivery of each of the residents' care needs and treatment.

Inspectors wroteBased on observation, interview and record review the facility failed to meet the requirement to provide 80 square feet (sq. ft- a unit of area measurement) per resident bedrooms. This deficient practice had the potential to result in inadequate space to provide privacy, space during daily care and access during an emergency.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident who was a high fall risk, with severe cognitive (ability to think and reason) impairment, and dementia (a progressive state of decline in mental abilities) did not fall and sustain a right hip fracture (a break in the bone) on 1/23/2025 after a previous fall on 3/22/2024 in which he sustained a left hip fracture (10 months part) for one of three sampled residents (Resident 1). The facility failed to: 1. Monitor Resident 1, who was assessed as a high fall risk and who sustained a previous fall with injury (3/22/2024), to prevent further accidents. 2. Supervise Resident 1 while outside on the facility's patio to prevent the resident from falling. 3. Ensure there was continuous supervision on the facility's patio to monitor Resident 1 and other residents to prevent accidents. 4. [...]

Inspectors wroteBased on interview and record review the facility failed to report an injury of unknown origin for one of three sampled residents (Resident 1), when Resident 1 had an unwitnessed fall and sustained a left hip fracture (a break in the bone). This deficient practice resulted in the inability of the California Department of Public Health (CDPH) to investigate Resident 1's injury in a timely manner and had the potential for information to be lost and/or forgotten.

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents have the right to be free from abuse for one of two sampled residents (Resident 1). This deficient practice resulted in Resident 2 slapping Resident 1 on the left cheek, potential placing Resident 1 to feel unprotected and other residents at risk of further abuse. a. During a review of Resident 1 ' s admission record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] and with diagnoses including dementia (a progressive state of decline in mental abilities), psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), any anxiety disorder (uncontrollable worry and fear about everyday situations). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure three out of 31 facility staff had an active Certified Nursing Assistant (CNA) certificate before providing direct resident care. This deficient practice had the potential to compromise residents safety as the uncertified staff may not be qualified to perform their duties. During a review of the December 2024 CNA monthly staff schedule, the monthly staff schedule indicated CNA 3 was scheduled to provide direct resident care. During a review of the Certificate Verification database (official site to verify certificate status for CNAs) for Certified Nursing Assistant 3 (CNA 3), the search page indicated there were no data found with CNA 3's certification status information. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the night shift staffs were being in serviced (staff education) for the same subjects as the day and evening shifts. This failure had the potential to jeopardize the safety of residents when staff members are not adequately educated. During an interview on 12/23/2024 at 3:56p.m. with the Director of Staff Development (DSD), the DSD stated she does the in services and come at different times to cover all of the shifts. DSD stated in services are done monthly, when there is an incident, or as needed. DSD stated for showers, it is on their assignments and is a part of their daily task for 7:00a.m. to 3:00p.m. (day) shift and 3:00p.m. to 11:00p.m. (evening) shifts, so the 11:00p.m. to 7:00a.m. (night) shift does not have to have an in service for showers since they do not give showers at night. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident, who was assessed as high risk for falls and had a self-release belt (a device designed for residents needing a reminder to call for assistance before exiting a wheelchair, for limiting unassisted exit and unwanted movement) while in a wheelchair for safety, did not fall out of the wheelchair and sustained injury for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure the Velcro (a type of material that consist of two pieces of cloth that stick together with a system of very small hooks used to fasten) used to secure Resident 1's self-release belt was not worn out and was in functional condition to keep the belt's ties securely fastened to prevent Resident 1 from falling out of the wheelchair when the resident leaned forward. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess, monitor, and document restraint monitoring flow sheet for three of three sampled residents (Resident 1, 2 and 3). This failure had the potential to result in siderail entrapment (occurs when a resident is trapped between a bed rail and the mattress, or within the rail itself),skin injury, accident, and compromised circulation.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure six out of six nurse aides successfully completed a nurse aide training and competency evaluation program. before allowing the nursing aides to provide direct resident care without supervision. This deficient practice had a potential for residents not getting appropriate care due to lack of training. Findings. During a review of the 7 a.m. to 3 p.m., daily assignment sheet dated 11/20/2024 indicated that Nursing Assistant (NA) 1 assignment was for Rooms 9-11. During a review of the 7 a.m. to 3 p.m. daily assignment sheet dated 11/19/2024 indicated that NA 1 assignment was for Rooms 6-8. During a review of the 7 a.m. to 3 p.m. daily assignment sheet dated 11/12/2024 indicated that NA 1 assignment was for Rooms 30-34. During a review of the 3 p.m. to 11 p.m. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the required in service training will be conducted upon hire and annually per facility ' s Policy and Procedure (P&P) titled Competency of Nursing Staff dated 5/2019. The facility failed to: a. Ensure sexual harassment or LGBQT (acronym for lesbian, gay, bisexual, transgender and queer) training was provided to Nurse aide (NA) b. Ensure required hours of dementia (progressive state of decline in mental abilities) training were provided upon hire and annually. c. Ensure abuse training was provided for NA1, NA3, NA6. d. Ensure Director of Staff Development have lesson plans (guide that outlines what staff will learn, how it will be taught, and how learning will be assessed) for abuse or infection control in-service training. Abuse mandated reporter in-service dated 5/3/2024 and 8/29/2024- no lesson plan. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two of three sampled residents (Resident 1 2 and Resident) were monitored during a smoking break while on the facility's patio by the appropriate number of staff in order to prevent a physical altercation between Resident 1 and Resident 2. This deficient practice resulted in a fracture to Resident 1's nose and Resident 1's transfer to a General Acute Care Hospital (GACH) where Resident 1 underwent a reduction (realignment of bones) of her nasal bones, and compression with rightward pressure to repair/straighten her nasal deviation.

Inspectors wroteBased on interview and record review, the facility failed to report a physical altercation between two of three sampled residents (Resident 1 and Resident 2), to the California Department of Public Health (CDPH), within two hours of the incident. On 8/18/2024 at approximately 8 a.m., facility staff witnessed Resident 2 elbow Resident 1 in her nose, resulting in Resident 1 sustaining a bloody nose, ecchymosis (bruising) to her nose and a nasal deviation (shifted to one side). The facility reported the incident on 8/18/2024 at 11:55 p.m., (approximately 16 hours after the incident occurred). This deficient practice resulted in CDPH being unaware of the abuse incident and injury to Resident 1 and had the potential for a delay in CDPH's investigation and other abuse allegations to go unreported.

Inspectors wroteBased on interview and record review, the facility's Quality Assessment and Assurance committee ([QAA] a group of facility staff who identifies, evaluates, and implements measures to improve the quality of care and life for the residents in the facility) and Quality Assurance Performance Improvement ([QAPI] a group who takes a systemic, interdisciplinary, comprehensive, and data driven approach to maintaining and improving safety and quality in nursing homes while involving residents and families, and all nursing home caregivers in practical and creative problem solving) committee failed to ensure continued oversight of the facility's plan of correction (POC) of the deficient practices identified during the previous abbreviated survey (5/28/2024) pertaining to abuse prevention and reporting. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident, who was totally dependent on staff for care and required a two-person physical assist to complete her activities of daily living ([ADL] task such as bathing, showering, dressing, transferring between surfaces including in and out of bed or a chair, walking, using the toilet and eating) did not sustain an injury while being transferred from a Geri-chair (a large, padded chair that is designed to help seniors with limited mobility) to a bed for one of three sampled residents (Resident 1). The facility failed to: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a STAT (immediate or urgent) X-ray (a medical procedure that creates pictures of the structures of the inside of the body) was ordered immediately for one of three sampled residents (Resident 1), when Resident 1 was assessed with swelling above her right knee and right posterior (back of) thigh, following a popping sound that was heard when Resident 1 was transferred from a Geri-chair (a large, padded chair that is designed to help seniors with limited mobility) to a bed. The facility failed to: Follow when STAT X-ray was ordered, and the physician did not return the call, when the STAT X-ray was eventually ordered, and the X-ray technician did not arrive to the facility in a timely manner, and when the STAT X-ray was taken and the results of the STAT X-ray was not received timely. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the nursing staff immediately initiate basic life support ([BLS] care healthcare professionals provide to anyone who's heart stops beating suddenly) including ([CPR] an emergency procedure to restart a person's heart and breathing after one or both suddenly stop) to one of three sampled residents (Resident 1), who became unresponsive on 7/26/2024 while in the dining room. The facility failed: 1. Ensure the Licensed Vocational Nurse ( LVN 3) did not instruct Certified Nursing Assistant (CNA 5) to wheel Resident 1 out from the dining room back to Resident 1's room so that CPR could be provided in the resident's room. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident, who was under conservatorship (a legal status in which a judge appoints a person [conservator] to manage the financial and personal affairs of a minor or incapacitated person) with a history of attempted elopement (an unauthorized departure of a patient from an around-the-clock care setting without the facility's knowledge and supervision), and assessed as high risk for elopement, did not elope from the facility for one of eight sampled residents (Resident 1). The facility failed to: 1. Ensure Resident 1, who on 3/23/2024, had attempted to elope from the facility by climbing over the patio's fence, did not elope from the facility on 6/16/2024 by climbing over the patio's fence. 2. [...]

Inspectors wroteBased on record review and interview, the facility failed to provide evidence that a thorough investigation of a resident-to-resident altercation between two of two sampled residents (Resident 1 and 2) was conducted or that a five-day summary was sent to the California Department of Public Health (CDPH). This deficient practice resulted in the allegation of abuse by Resident 1 against Resident 2 not being thoroughly investigated and the conclusion of the facility's investigation not being known by CDPH. This deficient practice had the potential to result in unidentified abuse in the facility and failure to protect residents from abuse.

Inspectors wroteBased on observation, interviews, and record review the facility failed to follow kitchen hygiene, handling, and storage of food products in the kitchen. a. By not dating an opened food items. b. Storing uncooked opened bag of raw fish on top of other raw meats in the refrigerator. These deficient practices had the potential to cause food borne diseases in the facility residents who depend on facility prepared food for daily feeding and contaminate other food stored in the refrigerator.

Inspectors wroteBased on observation, interview , and record review, the facility failed to ensure three of five sampled residents ( Resident 8, 58 and 69 ) were free of unnecessary physical restraints (any object or device that an individual cannot remove easily which restricts freedom of movement) by failing to: 1. Ensure on-going assessment and reevaluation of restraints' continuous use were conducted and documented. This failure had the potential to place Resident 8, 58 and 69 at risk for unnecessary prolonged use of restraints , impaired blood circulation, skin injuries and entrapment ( an event in which a patient is caught, trapped , or entangled).

Inspectors wroteBased on interview and record review, the facility failed to protect the health, welfare, rights and safety of 123 out of 123 residents by failing to screen potential employees for abuse, neglect (the failure to provide goods & services necessary to avoid physical harm, mental anguish, or mental illness), exploitation (the act of using someone or something unfairly for your own advantage), misappropriation of resident property (deliberate misplacement or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent) or mistreatment. This deficient practice placed residents at risk for abuse and neglect. Findings During a record review of the employee roster 2024, the employee roster indicated that since the last recertification in 2021, 1,005 new employees have been hired in the facility. [...]

Inspectors wroteBased on interview, and record review the facility failed to ensure Resident 73's responsible party (RP) was informed in advance, of the risks and benefits of psychotropic medication (a drug that changes brain function and results in alterations in perception, mood, consciousness, or behavior) for one of five sample resident's. This failure resulted into violating the residents' right to make an informed decision regarding the use of psychotropic medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify and assess one of five sampled residents (Resident 17) who had black discoloration and pain on his second toe of the right foot. This failure had the potential to cause delay of treatment and care to Resident 17.

Inspectors wroteBased on observation, interviews and record review, facility failed to provide psychiatric consult on Resident who is receiving antipsychotic medications in the facility for one of 10 sampled Resident (Resident 108). This deficient practice has the potential for Resident 108 receiving continuous unnecessary medications without Psychiatric evaluation.

Inspectors wroteBased on interview and record review, the facility failed to monitor side effects of Xarelto(medicine used to prevent blood clots and could cause increased risk of bleeding) on one of three residents (Resident 315). This failure had the potential to place Resident 315 at risk for undetected and potentially life-threatening side effects of Xarelto.

Inspectors wroteBased on observation, interview and record review, the facility failed to observe infection control measures by not practicing hand hygiene in between task of medication preparation. This failure had the potential to contaminate medicines in the medication cart and cause spread of infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staffing information was posted and placed in a visible and prominent place daily. This deficient practice resulted to unavailable information for number of staff and actual hours worked daily that is visible for residents and visitors.

Inspectors wroteBased on observation, interview and record review the facility failed to meet the requirement to provide 80 square feet per resident in multiple resident bedrooms. This deficient practice had the potential to result in inadequate space to provide privacy, space during daily care and access during an emergency.

Inspectors wroteBased on interview and record review, the facility failed to protect one of five sampled residents (Resident 1) right to be free from physical abuse by Certified Nursing Assistant (CNA) 3 when she slapped Resident 1 on the right side of the head and utter words in a threatening manner. This deficient practice resulted in Resident 1 was slapped by CNA 3 on the right side of the head and had the potential for Resident 1 to feel unsafe and unprotected.

Inspectors wroteBased on interview and record review, the facility failed to implement its abuse policy and procedure by failing to: 1. Protect one of five sampled residents (Resident 1) from physical abuse when Certified Nursing Assistant (CNA) 3 slapped Resident 1 on the left side of her head and utter words in a threatening manner. 2. Report to state agency (Department of Public Health) or the police department within two hours of the occurrence of incident and no later than 24 hours. These deficient practices resulted in CNA 3 slapped Resident 1 on the left side of her head and had the potential for Resident 1 to experience further abuse form CNA 3.

Inspectors wroteBased on interview and record review, the facility failed to ensure witnessed physical abuse were reported to the state agency (Department of Public Health (DPH) or the police department within two hours of the occurrence of incident and no later than 24 hours for one of three sampled residents (Resident 1). This deficient practice had the potential to result in unidentified abuse in the facility and had the potential for Resident 1 to experience further abuse from Certified Nursing Assistant (CNA) 3 and protect other residents from abuse.

Inspectors wroteBased on interview and record review, the facility failed to develop comprehensive care plan for one of five sampled residents (Resident 1) for abuse prevention. This deficient practice had the potential to negatively affect Resident 1 emotional and psychological wellbeing and affect the delivery of necessary care and services for Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor the temperature of resident rooms as outlined in the facility's policy and maintain a written log of the temperatures measured temperatures in the resident rooms. This deficient practice has the potential for all residents ' rooms to become too hot or too cold which could affect the safety and comfort of the residents at the facility.