Jurupa Hills Post Acute

Inspectors wroteBased on interview and record review, the facility failed to ensure the appropriate dosage of the medication Doxycycline (antibiotic used to treat bacterial infection) was given in treating the syphilis infection (a contagious sexually transmitted disease), for one of three residents reviewed for quality of care (Resident 1). This failure resulted in Resident 1 to not get the therapeutic dose of doxycycline required for treating the syphilis infection from March 8, 2026, to March 22, 2026, placing the resident at high risk for complications from delayed treatment. FindingsOn May 5, 2026, at 1:02 p.m., an interview was conducted with Resident 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe environment was provided, for four of four residents, when the residents were smoking in an area not designated for smoking and without supervision, according to the facility's smoking contract. This failure has the potential to place the residents for smoking-related safety risks.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents are free from verbal abuse from staff, for one of four residents reviewed (Resident 3). This failure had the potential for Resident 3 to experience emotional and psychosocial distress related to verbal abuse from staff.

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility's policy on abuse was implemented on conducting a thorough investigation when Resident 3 alleged she heard a Certified Nursing Assistant (CNA) made derogatory statements about her to other staff. This failure had the potential for a delay in the investigation of Resident 3's abuse allegation and could subject the resident and other residents for further abuse by the CNA.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were assessed/evaluated for continued use, for one of three residents reviewed (Resident 2), when propranolol (medication to treat high blood pressure) was held multiples times during the months of February, March, and April 2026. In addition, propranolol was administered to Resident 2 when the SBP (systolic blood pressure - the top number in a blood pressure reading which is the highest pressure in your arteries, measured in mmHg (millimeters of mercury) when the heart muscle contracts and pumps blood) < (less than) 110, according to the physician's order. These failures had the potential to place Resident 2 at risk for unnecessary medication and to experience adverse reactions of low blood pressure.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Eliquis (blood thinner medication) was resumed 48 hours post (after) procedure, as ordered by the physician, for one of seven residents reviewed (Resident 1). This failure had the potential to increase the resident's risk of developing blood clots and placed the resident at risk for further complications.

Inspectors wroteBased on interview and record review, the facility failed to implement interventions to address aggressive behavior towards other residents were provided, for one of seven sampled residents (Resident 4), when Resident 4 continued to have aggressive behavior towards other residents placed in the room with Resident 4. In addition, the facility continued in assigning a roommate to Resident 4, even after a trigger for the resident's aggressive behavior had been identified. This failure resulted in foreseeable risk of harm, escalation of behaviors and decline in the resident's psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, for one of four residents reviewed for quality of care (Resident 5):1. A physician's order to schedule a follow up orthopedic (branch of surgery concerned with conditions involving the musculoskeletal system) appointment, related to left shoulder rotator cuff tear (RCT - injury to the group of muscles and tendons that stabilize the shoulder causing pain, weakness, and limited arm movement) was done. This failure resulted to the delay treatment and services, putting Resident 5 at high risk for complications from the left shoulder rotator cuff tear; and2a. An assessment was conducted and documented prior to obtaining an order to increase dose in Gabapentin (medication used to relieve nerve pain) on November 11, 2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, for one of three residents (Resident 1):1. An environment free from accident hazards, when a resident (Resident 1) was able to gain access and ingest a packet of hydrocortisone (steroid ointment) without the staff knowledge. This failure resulted in the hydrocortisone packet getting lodged to the resident's throat causing the resident to choke while eating, which could subsequently obstruct the resident's airway leading to a loss of consciousness and death. Resident 1 was transferred to the general acute hospital (GACH), for evaluation and treatment; and2. The incident related to finding the hydrocortisone packet lodged in the resident's throat was thoroughly investigated. This failure placed the resident at risk of recurrence and further harm.

Inspectors wroteBased on interview and record review, the facility did not ensure that new medical orders were implemented in a timely manner after an orthopedic (specialty focusing on musculoskeletal system) consultation for one of one resident (Resident 2) reviewed. This failure caused a delay in treatment and services for Resident 2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure professional standards for food safety were upheld when:1. Several kitchen staff did not wear hairnets properly; and2. The Dishwasher did not change gloves after touching dirty kitchenware and before touching the clean and sanitized large SS pans coming from the dishwashing machine. In addition, during the dishwashing process, multiple kitchenware which had crusted food residue on them, were rinsed above and beside beverage cups and glasses. This failure had the potential to cause food-borne illness in a highly susceptible population of residents who could consume food.

Inspectors wroteBased on interview and record review, the facility failed to ensure a copy of the notice of transfer/discharge was provided to the State Long-Term Care Ombudsman (assists with conflict resolution and protection of resident rights) prior to the planned discharge date , for two of two sampled residents (Residents 1 and 2). This failure had the potential to violate the resident's rights to appeal their discharge.

Inspectors wroteBased on interview and record review, the facility failed to ensure pain management was provided according to the physician's order and plan of care, for one of ten (Resident A). This failure had the potential to result in Residents A's pain to not be managed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. For Residents 57 and 48, the nursing staff failed to properly clean and disinfect the shared blood pressure (BP-pressure of blood in blood vessels) cuffs and stethoscope according to the disposable wipe manufacturer's specified contact time (the time the resident equipment was to be in contact with the disposable wipes to kill micro-organisms), for two of four residents observed during medication administration observation; and 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an assessment and evaluation for self-administration (taking medication or substance by oneself, rather than by a healthcare professional) of medication albuterol inhaler (used to prevent and treat wheezing, difficulty breathing, chest tightness, and coughing caused by lung disease such as asthma) was completed, for one of 27 residents reviewed (Resident 180). In addition, the facility failed to ensure the medication was stored safely and securely. This failure increased the potential for unsafe self-administration and duplication of administered medication for Resident 180, and potential for visitors, and other residents to have access to the medication at bedside.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate the needs, for one of two residents reviewed (Resident 56), when Resident 56 was not provided appropriate bed for the resident's height. This failure resulted in Resident 56 not to have his preference to use a bed tall enough to accommodate his height and had discomfort when lying in bed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care and services to maintain cleanliness and proper hygiene of resident's fingernails, for one of 27 residents reviewed (Resident 115). This failure had the potential to negatively impact the physiological and psychological well-being of Resident 115. In addition this failure had the potential to result in cross contamination of bacteria underneath the dirty fingernails to Resident 115's food during meals.

Inspectors wroteBased on interview and record review, the facility failed to ensure care and treatment according to the professional standards of practice and physician's order was provided, for one of 24 residents (Resident 105) when Insulin Lispro (a type of insulin medication) was administered to Resident 105 when the blood sugar level was below below the hold parameter). This failure had the potential for Resident 105 to experience hypoglycemia (a condition in which the body's blood sugar level goes below the standard range).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who is fed by enteral means (directly to the gastrointestinal system or stomach) receives the appropriate care to prevent complications of enteral feeding when, one of one resident reviewed for tube feeding (Resident 122), was positioned with the head of the bed (HOB) not elevated 30-45 degrees while receiving tube feeding (nutrition provided through a tube inserted into the stomach). This failure had the potential for Resident 122 to experience complications from tube feeding, such as aspiration (when food or liquid or other materials enters the airway and lungs instead of being swallowed) , nausea, vomiting, or abdominal pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care and treatment, for one of two residents reviewed for oxygen administration (Resident 101), when the physician's order for oxygen administration was not followed. This failure had the potential to result in ineffective oxygen therapy, respiratory distress, and decline in the resident's health condition.

Inspectors wroteBased on interview and record review, the facility failed to request a medication regimen review (MRR) following changes in condition (worsening of an existing problem or the emergence of new signs or symptoms, such as falls), and failed to ensure the consultant pharmacist (CP) identified potential medications contributing to falls and make recommendations to the facility for reduction or discontinuation of the medications during the monthly MRRs for one out of five sampled residents (Resident 35). This failure had the potential for medications not being optimized for best possible health outcome, and unnecessary or prolonged use of medications which could lead to medication adverse effects (such as falls) for the resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 74) was free from unnecessary psychotropic (drugs that affects brain activities associated with mental processes and behavior) medications when administered buspirone (used to treat anxiety) without behavioral monitoring. This failure had the potential to result in unnecessary use of medications for Resident 74 which increased the potential for medication interactions, adverse reactions, and unidentified risks associated with the use of psychotropic medications that included but not limited to dizziness, nausea, headache, and nervousness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (Resident A) of four sampled residents' wheelchair was maintained in a safe and operable condition. This failure had the potential to cause injury to Resident A when he is using a wheelchair with two broken wheel brakes.

Inspectors wroteBased on interview and record review, the facility failed to follow their grievance policy and procedure for one resident, (Resident 1) when the family representative (FR) expressed concerns about Resident 1 ' s care. This failure may have contributed to a delay in response to verbal concerns submitted on behalf of Resident 1.

Inspectors wroteBased on interview and record review, for one of three residents reviewed (Resident A), the facility failed to ensure the effectiveness of the interventions to prevent falls were evaluated, and new interventions were implemented to address Resident A ' s repeated falls due to behavior of getting up unassisted and prevent further falls. These failures resulted in Resident A to have 16 falls from October 16, 2023, to February 13, 2024, while at the facility. Resident A ' s fifth (5th) fall resulted to the resident to sustain a laceration (cut) on the back of his head and was treated in the emergency room (ER) with two staples (used to close wounds) placed on the laceration. Resident A ' s ninth (9th) fall resulted to the resident to sustain a skin tear on the right elbow. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision while smoking, to one of three sampled residents (Resident C). In addition, the facility failed to ensure smoking paraphernalia was not kept in possession of the residents in accordance with the facility policy and procedure. These failures resulted in Resident C to cause physical harm to Resident A and Resident B. Resident C hit Resident B in the face; and Resident C burnt Resident A's arm with a lit cigarette while at the smoking patio, on June 9, 2024, resulting in Resident A to sustain a cigarette burn on the right arm.

Inspectors wroteBased on interview, and record review, the facility failed to ensure two of seven sampled residents' (Resident D and Resident E) pain were managed consistent with professional standards of practice, and the residents' comprehensive person-centered care plans, when the residents did not receive pain medications in accordance with the physician orders. This failure has the potential to negatively affect the health status of Residents D and E.

Inspectors wroteBased on interview and record review the facility failed to ensure one of seven sampled residents (Resident D) received treatment and care in accordance with professional standards of practice, when the new physician orders from a consulting physician ' s office were not initiated as soon as the resident came back to the facility. This failure has the potential to result in worsening of Resident D ' s autoimmune disease (when the body ' s immune system attacks itself).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of seven sampled residents (Resident E) was assessed properly for bladder and bowel control. This failure had the potential for Resident E to not be identified, assessed, and provided appropriate treatment and services to achieve as much bladder and bowel function as possible.

Inspectors wroteBased on interview, and record review, the facility failed to implement their policy and procedure on abuse, for one of three residents, (Resident 1) when the facility failed to develop a plan of care to ensure safety of the resident including notifying the staff of the incident and interventions to prevent further abuse on Resident 1. This failure resulted in the facility staff to not be informed of necessary information to ensure safety and protection for Resident 1 and further place Resident 1 at risk for further abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of financial abuse was reported to the California of Department of Public Health (CDPH) immediately, or not later than two hours, when the facility received a report of the abuse allegation from the General Acute Hospital (GACH) staff, for one of three residents reviewed (Resident 1). This failure had the potential to result in a delay of the implementation of appropriate action and the provision of protection for Resident 1 and placed other residents at risk for further abuse.

Inspectors wroteBased on observations, interviews, record review, and facility document and policy review, the facility failed to implement a system that allowed staff to quickly and accurately identify code status (describes the type of interventions to be provided when an individual is found without a pulse or not breathing) in the event of an emergency and failed to honor the advance directive of 1 (Resident #32) of 4 sampled residents reviewed for advance directives. Specifically, on [DATE], staff initiated cardiopulmonary resuscitation (CPR) when Resident #32 was found unresponsive, despite the resident having a signed physician's order for life sustaining treatment (POLST) and an advance directive on file that indicated the resident elected do not resuscitate (DNR) in the event they were found not breathing or without a pulse. [...]

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to ensure food was prepared and served in a manner to prevent potential cross contamination. Specifically, staff failed to utilize a beard restraint while preparing drinks for meal service, and another staff member failed to wash their hands and change gloves when leaving the meal service line to prepare a quesadilla. These failures had the potential to affect 125 of 125 residents who received meals from the dietary department.

Inspectors wroteBased on observations, interviews, record reviews, and facility document and policy review, the facility failed to test staff identified via contact tracing as having a high-risk COVID-19 exposure. This had the potential to affect all residents who resided in the facility. Additionally, the facility failed to ensure that perineal care was performed in a sanitary manner for 1 (Resident #51) of 1 resident observed during perineal care.

Inspectors wroteBased on interviews, record review, facility policy review, and review of the California Department of Health Care Services Preadmission Screening and Resident Review (PASRR) Level 1 Assessment Guide, the facility failed to ensure the accuracy of Level I PASRR screenings completed for 2 (Resident #12 and Resident #110) of 5 sampled residents reviewed for PASRR requirements.

Inspectors wroteBased on interviews, record review, facility policy review, and review of the California Department of Health Care Services Preadmission Screening and Resident Review (PASRR) Level 1 Assessment Guide, the facility failed to submit a status change to a level I PASRR following a new mental health diagnosis for 1 (Resident #58) of 5 sampled residents reviewed for PASRR requirements. Specifically, Resident #58 had a prior positive level 1 PASRR but was later diagnosed with a new mental health diagnosis, and the facility failed to submit a status change to the resident's level 1 PASRR evaluation.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure the resident's medication regimen was free from unnecessary medications for 1 (Resident #58) of 5 sampled residents reviewed for unnecessary medications. Specifically, Resident #58 had an order for lorazepam (a benzodiazepine that may be used to treat anxiety) that was started on 02/08/2024 with no stop date or re-evaluation for continued use.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to follow vital sign parameters when administering medications for 1 (Resident #58) of 5 sampled residents reviewed for unnecessary medications. Specifically, facility staff failed to hold medications when Resident #58's Systolic Blood Pressure (SBP) was less than (<) 110 millimeters of mercury (mmHg) as outlined in the physician's order.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to maintain medical records that were accurately documented for 1 (Resident #31) of 5 sampled residents reviewed for unnecessary medications.

Inspectors wroteBased on interview and record review, the facility failed to provide the survey agency (CDPH - California Department of Public Health) a written result of the abuse investigation within five (5) calendar days, for one of three sample residents (Resident A). This facility failure had the potential in a delay in the implementation of the intervention to ensure Resident A's safety and may place the residents at risk for further abuse.

Inspectors wroteBased on interview and record review the facility failed to demonstrate a rationale for a one of three sampled residents' (Resident 1) transfer to a board and care. In addition, the facility failed to complete a thorough discharge summary to reflect post-care provider relevant for the continuity of care for Resident 1. These failures had the potential to jeopardize the health and safety of Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure reasonable care for the protection of personal property for one of four sampled residents (Resident 1). This failure resulted in the loss or theft of Resident 1's personal property.

Inspectors wrote3. On June 9, 2021, Resident 22's record was reviewed. Resident 22 was readmitted to the facility on [DATE], with diagnoses including sepsis (a life-threatening complication of an infection). The Social History Assessment, dated March 10, 2021, indicated Resident 22's family member was contacted but there was no documented evidence a written information or assistance was offered to the family member regarding formulating an advance directive. On June 9, 2021, at 3:25 p.m., a concurrent interview and record review was conducted with SSD 2. SSD 2 stated there was no documentation a written information regarding formulating an AD was provided to Resident 22's RR. 2. On June 9, 2021, Resident 87's record was reviewed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care and treatment were provided for three of 26 residents reviewed (Residents 172, 423, and 14) when: 1. For Resident 172, proper bowel management was not provided to address constipation (difficult bowel movement [BM]). This failure resulted in Resident 172 to experience discomfort and had the potential to result in complications related to constipation. 2. For Resident 423, the intravenous medication (IV - administration of fluids or medication through the vein) vancomycin (an antibiotic to treat infection) was not administered in a timely manner. In addition the physician was not notified when the IV medication was not administered timely. This failure had the potential for a delay of treatment for Resident 423. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the nutritional needs of the residents (Residents 20, 110, 39, 2, 70, 81, 16, 12, and 47) were met when: 1. The large portion diet was observed not in accordance with the production/dietary spreadsheet (used to determine the amount of food to serve for menu production), potentially affecting all residents on large portion diet; 2. The renal diet (diet for individuals with kidney disease) for Resident 39 was not served in accordance with the production/dietary spreadsheet; and 3. Multiple residents did not receive the designated vegetables on their food tray when the facility ran out of vegetables. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sanitary conditions were maintained in the food and nutrition services and food were stored in accordance with professional standards for food service safety when: 1. One can of tapioca pudding was observed with a dent on the side of the can; 2. An open box of 25 pounds (lbs) of rice was not placed in a closed container; and 3. Food items were stored past the use-by-date. These failures had the potential for the growth of harmful microorganisms which may result in food-borne illnesses in a medically vulnerable population.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate the resident's request for the use of a denture adhesive for one week, for one of one resident reviewed (Resident 173). This failure resulted in Resident 173's frustration of constantly cutting the food served during meals and not using his dentures to chew his food. In addition, this failure had the potential for Resident 173 to not to consume his food and may result in weight loss.

Inspectors wroteBased on interview and record review, the facility failed to conduct a thorough investigation for an allegation of abuse against a staff member for one of two residents reviewed for abuse (Resident 91). This failure had the potential to put Resident 91 and other vulnerable residents at risk for abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate screening for PASARR (Preadmission Screening and Resident Review - a federal program to prevent individuals with mental illness, intellectual disability or related conditions from being inappropriately placed in a nursing facility), was conducted for one of one resident reviewed for PASARR. This failure had the potential for Resident 34 to not be properly evaluated and not receive appropriate care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the discharge (D/C) plan was discussed with the resident, for one of one resident (Resident 32) reviewed for discharge. This failure had the potential for Resident 32 to not be aware and/or participate with the D/C plan.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure assistance during meals was provided, for one of one resident reviewed (Resident 13), when the resident was eating the pureed food using her hands. This failure had the potential for Resident 13 to not be able to consume the food served and could place the resident at risk for nutritional problems.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide bilateral floor mats, as ordered and as indicated in the care plan to address the resident's fall risk, for one of three residents reviewed (Resident 22). This failure had the potential for Resident 22 to be at risk for injury and accidents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nutritional care and services were provided, for two of four residents reviewed for nutrition (Residents 34 and 15), when: 1. For Resident 34, the physician was not notified in a timely manner of the IDT (Interdisciplinary Team - a group of healthcare professionals who work together for the common goal of the resident) recommendations to address the resident's significant weight loss. Weekly weights were not obtained when Resident 34 had significant weight losses in March, April, and May 2021. In addition, the physician was not notified of Resident 34's refusal for laboratory tests; and 2. For Resident 15, the facility did not provide the resident's meal preference to add soup with lunch and dinner to address the resident's significant weight loss. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a physician's order was obtained for the use of oxygen, for one of two residents reviewed for oxygen use (Resident 110). This failure resulted in Resident 110's continuous oxygen use without a specific physician's order. This failure had the potential for Resident 110 to receive unnecessary oxygen treatment without proper physician's evaluation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to carry out the physician's order for fluid restriction for one of two residents (Resident 79) reviewed for dialysis (process of removing excess water, solutes and toxins from the blood in people whose kidneys can no longer perform these functions naturally). This failure also had the potential for Resident 79 to have fluid overload (the condition of having too much water in the body) and further compromise his physical health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drinks were provided according to the residents' needs, for four of four residents reviewed (Residents 13, 113, 4, and 39), when: 1. Residents 13 and 113, who had fortified diet orders, were not provided eight ounces (oz - unit of measurement) of milk as specified in the menu; and 2. Residents 4 and 39, who had renal diet (diet provided to residents with kidney disease) orders, were not provided pineapple juice as specified in the menu. These failures had the potential for Residents 13, 113, 4, and 39 to not receive the appropriate nutrients needed to address their health conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. The urinal of Resident 2 was labeled with his name. This failure had the potential for cross contamination to occur when used by other residents, which could result for Resident 2 and other residents to develop bladder infection. 2. The medication nebulizer mask with dispenser (medication dispenser attached to a machine used to administer breathing treatment) for Resident 44 was stored inside a bag when not in use; and 3. The oral suction catheter of Resident 96 was stored inside a bag when not in use. These failures had the potential for bacterial growth and increased the risk for Residents 44 and 96 to develop respiratory infection.