Kei-Ai South Bay Healthcare Center

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was confused with diagnoses of metabolic encephalopathy (a general term for any disease, damage, or malfunction of the brain that causes altered mental states such as confusion, memory loss, and personality changes), unspecified psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), and exhibited exit seeking behaviors, did not elope (the act of leaving a facility unsupervised and without prior authorization) from the facility on 7/25/2026 by failing to:Follow its Policy and Procedure (P&P) titled, Elopement Prevention and Management, which indicated residents who exhibit wandering (the random or repetitive locomotion that may be goal-directed [i.e. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Transfer and Discharge, for one of 3 residents (Resident 1), by failing to:Provide Resident 1 Notice of Medicare Noncoverage ([NOMNC], a document issued to inform residents when Medicare-covered care is ending) document in a manner Resident 1 understood. Provide Resident 1 Notice of Discharge to Resident 1 at least 30 days prior to discharge. These failures had the potential to result in miscommunication and Resident 1's discharge needs were not met.

Inspectors wroteBased on interview and record review, the facility failed to develop a resident-centered, comprehensive care plan (a detailed, individualized guide of the care needed to provide the resident according to the patient's medical, physical, emotional, and social needs) for one of three sampled residents (Resident 1), who speaks Japanese language (official and primary language of Japan). This failure had the potential for Resident 1's needs to be left unmet.

Inspectors wroteBased on interview and record review, the facility failed to revise the care plan to include person-centered safety measures such staff supervision and monitoring for one of five sampled residents (Resident 1) who was at high risk for falls, had decreased postural alignment (misalignment or imbalance of the body's musculoskeletal structures), poor standing balance (moderate assistance and upper extremity support to stand and reach without loss of balance; unable to weight shift) and impaired safety awareness. This deficient practice resulted in Resident 1 having unwitnessed falls on 11/22/2025, 11/24/2025 and 11/28/2025, and placed the resident at risk for injuries, hospitalization or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label a container of dehydrated mashed potatoes with a use by date and failed to properly sanitize (the process of keeping places free from dirt, infection, disease) cookware. This failure had the potential to result in the preparation and provision of expired food for the residents and the potential to result in the use of improperly sanitized cookware used to prepare food for the residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure one of seven sampled residents (Resident 61) Certified Nursing Assistant (CNA) 1 was seated while feeding Resident 61. This deficient practice of CNA 1 was not seated while feeding Resident 61 had the potential to make her feel uncomfortable. During a review of Resident 61'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 61 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 61's diagnoses dysphagia (difficulty swallowing), hemiplegia (paralysis of the arm, leg, and trunk on the same side of the body), and gastro-esophageal reflux disease ([GERD]- a chronic condition of frequent backflow of stomach acid into the esophagus). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure one of seven sampled residents (Resident 103) had a consent (when a patient agrees to a treatment or procedure understanding of the risk and benefits of treatment) for the antipsychotic medication Seroquel (medication to manage schizophrenia, bipolar, and major depressive disorder). This deficient practice of not obtaining consent antipsychotic medication Seroquel had the potential for Resident 103 not to be educated on the risk and benefits of the medication. During a review of Resident 103'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 103 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure one of seven sampled residents (Resident 112) was weighed on and after admission. This deficient practice of not weighing Resident 112 upon admission and after had the potential to not keep track of weight loss. During a review of Resident 112'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 112 was admitted to the facility on [DATE]. Resident 112's diagnoses benign prostatic hyperplasia (enlargement of the prostate gland), dermatitis (chronic skin inflammation), and gastro-esophageal reflux disease ([GERD]- a chronic condition of frequent backflow of stomach acid into the esophagus). [...]

Inspectors wroteBased on interview and record review the facility failed to ensure two of seven sampled residents (Residents 77 and 103) had comprehensive individualized care plans addressing:Resident 103's anti-psychotic medication Seroquel (a medication to treat [schizophrenia]- a mental illness that is characterized by disturbances in thought). 2. Resident 77's peripherally inserted central catheter ([PICC]- a long thin tube inserted into the upper arm to give medication) line. This deficient practice placed residents at risk for unrecognized medication side effects and PICC-related complications due to the absence of staff guidance in the care plan.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Review, update, and/or revise the care plan to address use of Low Air Loss (LAL) mattress for two of three sampled residents (Residents 2 and 14). This deficient practice had the potential to affect the delivery of necessary care and treatments for Residents 2 and 14.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure one of seven sampled residents (Resident 97) sling (an orthopedic appliance used to immobilize, support, or protect an injured limb) device was on his right arm. This deficient practice of not placing a sling to Resident 97's right shoulder placed him at risk for dislocation (when a bone is forced out of its normal position at a joint). During a review of Resident 97'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 97 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to:Ensure low air loss (LAL- aim to improve comfort, and circulation, and reduce the risk of pressure ulcers) mattresses were set to the appropriate weight settings for three of eight sampled residents (Residents 2, 14 and 103). This deficient practice placed residents at risk for ineffective pressure redistribution, discomfort, pain, and pressure ulcer development or worsening. B.During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] and last readmitted on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of seven sampled residents (Resident 112) the physician was notified when there was sediment (the solid matter that settles to the bottom of a liquid, such as urine or blood) in the indwelling catheter (a medical device inserted into the bladder to drain urine continuously) tubing. This deficient practice not notifying the physician of the sediment in the indwelling catheter tubing had the potential to cause a urinary tract infection ([UTI]- an infection in any part of the urinary system). During a review of Resident 112'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 112 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure a peripherally inserted central catheter ([PICC]- a long thin tube inserted into the upper arm to give medication) dressing was labeled with a date, time and initials for one of one sampled resident (Resident 77). This deficient practice had the potential for the PICC line insertion site to develop an infection and/or hospitalization for Resident 77.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Obtain physician orders prior to initiating low air loss (LAL) mattress therapy for two of eight sampled residents (Residents 2 and 14). This deficient practice had the potential to result in unnecessary treatment and adverse outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure one of seven sampled residents (Resident 99) eye drop medication Timolol (medication to treat high pressure inside the eye) was properly stored. This deficient practice of leaving the eye drop medication Timolol at bedside had the potential for the medication to be used by other residents. During a review of Resident 99'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 99 was admitted to the facility on [DATE]. Resident 99's diagnoses hemiplegia (paralysis affecting one side of the body), chronic obstructive pulmonary disease ([COPD]- a chronic lung disease causing difficulty in breathing) and anxiety (an uneasy feeling of discomfort, apprehension, or dread to a non-specific or unknown threat). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 3 of 4 outside trash bin lids were completely closed. This failure had the potential to result in odors attracting pests and scavengers (organisms that feed on dead matter) to the trash bins.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the urinal bottle (handheld container for pee) for Resident 113 had a cover to prevent spillage of urine. This failure had the potential to result in urine spilling onto staff or Resident 113 during care.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents' (Resident 1) transfer summary was completed, and telephone report was called to the receiving facility, prior to discharge on [DATE], as indicated in the facility's policy and procedure (P&P) titled, Discharging the Resident. This failure caused Resident 1's discharge to the independent living facility (ILF, a community for active seniors who want to maintain their independence but desire the benefits of a maintenance-free lifestyle and community amenities, such as dining, fitness centers, housekeeping, and social activities) on 8/20/2025, who could not fully provide and accommodate the resident's needs and had the potential to affect the resident's highest practicable physical, mental and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to provide staff supervision for 2 of three sampled residents (Resident 1 and 2) by failing to ensure Resident 1 and Resident 2 were separated immediately by staff when Resident 2 was verbally aggressive towards Resident 1. This failure resulted in Resident 2 hitting Resident 1 on the left side of the face.

Inspectors wroteBased on interview and record review the facility failed to ensure one out of three sampled residents (Resident 1) had an accurate resident assessment (the process of systematically evaluating a resident's needs, strengths, and preferences to promote quality of life) on the Minimum Data Set ([MDS]- resident assessment tool) assessment for wandering (a resident tendency to move about aimlessly repeatedly). This deficient practice of not accurately documenting on the MDS of Resident 1 wandering behavior placed the residents at risk of not receiving accurate treatment

Inspectors wroteBased on observation, interview and record review, the facility failed to place the call light buttons for 4 of 6 sampled residents (Residents 2, 4, 5 and 6), within their reach. This deficient practice placed Residents 2, 4, 5, and 6 at risk for not being able to call for help when needed and can result to needs not being attended to timely. This deficient practice had the potential to cause falls, other injuries, including hospitalization and death.

Inspectors wroteBased on interview, and record review, the facility failed to follow its policy and procedure (P&P) titled, Transfer and Discharge Notice, when three of three residents (Resident 1, 2, 3) and their representatives did not receive written notification of transfer after transfer to the general acute care hospital (GACH). This failure had the potential for Resident 1's, Resident 2's, and Resident 3's representatives to not know their transfer rights and destination of the residents' transfers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) titled, Physician Services, which indicated physicians must perform the initial face-to-face visit, sign admitting physician orders, and perform alternating visits with a non-physician practitioner (NPP), for one of three residents (Resident 1). This failure had the potential for Resident 1 to not be thoroughly assessed, not receive safe and adequate care.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure one out of seven residents (Resident 73) had a privacy bag for the indwelling catheter (a device that is inserted into the bladder that collects and drain urine). This deficient practice of not covering the indwelling catheter had the potential to effect Resident 73's dignity.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure one out of seven sampled residents (Resident 45) had the call light (a button or device that a patient can press to signal a nurse or healthcare provider that they need assistance) within reach. This has the potential for the resident's needs will not be met promptly.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure one out of seven sample residents (Resident 144) had trimmed fingernails. This failure of not properly trimming Resident 144's fingernails had the potential to cause skin breakdown (a tear, blister, or cuts of the skin with the destruction of tissue and discomfort).

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure one out of seven sampled residents (Resident 84) the low air loss ([LAL] a mattress that helps prevent and treat pressure injuries) mattress had the correct settings. This deficient practice of not having the correct LAL mattress settings had the potential for Resident 84 to have skin breakdown (damage to the skin or underlying tissue caused by a loss of blood flow).

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure one out of seven sampled residents (Resident 143) to follow physician orders for oxygen therapy (a medical treatment that provides extra oxygen to a patient through a mask or nasal cannula). This failure had the potential of the resident not receiving appropriate medical care.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure blood pressure medication was administered in a timely manner for one of 7 sampled residents (Resident 36). This deficient practice had the potential to result in high blood pressure, dizziness, and a stroke.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure the medication error rate was less than 5% for two of 2 sampled residents (Resident 36 and resident 148). This deficient practice had the potential to affect the efficacy and side effects of the medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure medication was ordered from the pharmacy for one of 8 sampled residents (Resident 148). This deficient practice resulted in Resident 148 missing 9 doses and had the potential to result in resident exhibiting physical aggression, restlessness, and manic behavior.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure Tylenol suppositories (a rectal medication used to relieve mild to moderate pain from headaches or muscle aches and to reduce a fever) stored in a clear, Ziplock bag was labeled and dated in the Station 1 Medication Storage room. This deficient practice had the potential to result in medication errors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure dental services were provided for one of 7 sampled residents (Resident 35). This deficient practice had the potential to result in a delay in necessary dental care and services.

Inspectors wroteBased on observation and interview the facility failed to change oxygen tubing in seven days for one out of five Residents (Resident 66). This deficient practice placed Resident 66 at risk for infection.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure (P&P) titled Change in Resident's Condition or Status for one of three sampled residents when the facility failed to notify a resident's representative within 24 hours of a significant change in Resident 1's health status. This failure resulted in a violation of Resident 1's rights.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a care plan for one of three sampled residents (Resident 1) after a new wound was identified. This failure had the potential to result in Resident 1 not receiving appropriate care and developing an infection and further skin breakdown.

Inspectors wroteBased on interview and record review, the facility failed to provide one of three residents (Resident 1) with a physician-ordered computerized tomography scan (CT scan- an imaging test that helps detect diseases) and general surgeon referral. This failure had the potential to result in a delay in care and worsening of Resident 1's localized swelling and severe ascites (fluid buildup in the abdomen).

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection prevention precautions for one of three sampled residents (Resident 1) when Resident 1's wound dressing was soiled and not changed, and when one certified nursing assistant (CNA 1) did not wear required personal protective equipment (PPE) when providing care to Resident 1. These failures had the potential to result in contamination and infection of Resident 1's wound and spread of Resident 1's infection to other residents and staff members.

Inspectors wroteBased on interview and record review, the facility failed to provide the necessary care and services for one of three sampled residents (Resident 1) by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 2 reassessed Resident 1 after a change of condition ([COC] a sudden or gradual change in a patient's physical, cognitive, behavioral, or functional status) of wheezing (when breathing becomes difficult due to narrowed or blocked airways in the lungs), vomiting, and sweating on 9/15/2024 at 8:00 a.m. This deficient practice resulted in Resident 1's death, at 10:57 a.m., approximately 3 hours after she was observed with shortness of breath, wheezing, vomiting, and sweating.

Inspectors wroteBased on interview and record review, the facility failed to document vital signs after treatment for shortness of breath, wheezing, vomiting, and sweating interventions were performed, for one of three sampled residents, (Resident 1). This failure had the potential for vital signs not taken, the necessary care and services Resident 1 would have needed not provided, and contributed to Resident 1 ' s death on [DATE] at 10:57 a.m.

Inspectors wroteBased on observation, and interview, the facility failed to ensure the licensed nurse performed hand washing or hand sanitizing in between changing to new pair of gloves, when wound care were performed for three of five sampled residents (Residents 2, 3, and 4). This deficient practice had the potential for cross contamination and to spread infection between resident which could result to delay in wound healing and wound infection.

Inspectors wroteBased on interviews and record review, the facility failed to develop a comprehensive care plan for one of three sampled residents (Resident 1) who was refusing to participate in Restorative Nurse Assistant (RNA) program due to pain. This deficient practice had the potential to result in unidentified interventions to address Resident 1 ' s refusal and negatively affect the resident ' s well-being.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly assess and monitor an elevated skin (lump like) for an increase in size, for one of three sampled residents (Resident 1) according to the physician ' s order and the facility ' s Policy and Procedure (P&P). This deficient practice had the potential to result in a delay in necessary treatment and worsening of the skin condition/lump for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to implement proper pain management to one of three sampled residents, (Resident 1). This failure had the potential to result in a decline in activities of daily living and mobility when pain was not managed.

Inspectors wroteBased on interview and record review, the facility failed to ensure timely notification to the physician was conducted for one of three sampled residents ' (Resident 1) abnormal urinalysis (analysis of urine by physical, chemical, and microscopical means to test for the presence of disease) results. This deficient practice resulted in the delay of the urinary tract infection ([UTI] when bacteria enter the urinary tract; kidneys, bladder, or urethra) treatment for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to implement its abuse policy and procedure (P&P) titled, Abuse Reporting and Investigation, by failing to report misappropriation of funds to the State Licensing Agency (SA) within two hours, for one out of three sampled residents (Resident 2). This deficient practice resulted to the delay in investigation by the California Department of Public Health (CDPH).

Inspectors wroteBased on interview and record review, the facility failed to ensure a thorough investigation was conducted for one of three residents (Resident 2), after alleged fraudulent (unauthorized) charges were reported to the facility by the Ombudsman ' s office (patient advocate). This deficient practice resulted to the misappropriation of Resident 2 ' s funds and placed Resident 2 and other residents at risk for further financial abuse.

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately document provision of Restorative Nursing Assistant (RNA) services for three of three sampled residents (Resident 1, Resident 5 and Resident 6). This deficient practice had the potential to negatively affect delivery of care/services to Residents 1, 5 and 6.

Inspectors wroteBased on interview and record review, the facility failed to implement its Policy and Procedure (P&P) titled, Abuse Reporting and Investigation dated 1/10/2024 which indicated, all allegations of abuse would be reported to the California Department of Public Health (CDPH) within 2 hours for two of five sampled residents (Resident 1 and Resident 4) after Resident 1 threw water towards Resident 4. This deficient practice had the potential for the underreporting of abuse incidents and a delay in the investigation by the CDPH.

Inspectors wroteBased on observation, interview and record review, the facility failed to thoroughly investigate an allegation of abuse and separate two of five sampled residents (Resident 1 and Resident 4) after Resident 1 reported to Certified Nurse Assistant (CNA) 5, he threw water at Resident 4 on 3/14/2024. This deficient practice had the potential to result in unidentified abuse and ongoing abuse for Resident 4.

Inspectors wroteBased on interview and record review, the facility failed to ensure skin treatment was provided and monitoring for bilateral (both) upper and lower extremities (arms and legs) swelling were conducted according to the physician ' s orders for one of four sampled residents (Resident 1). These failures had the potential to result in the worsening of Resident 1 ' s skin condition and could negatively affect the resident ' s health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) received care and services to prevent the development of a pressure ulcer (damage to the skin and/or underlying skin tissue) according to the physician ' s orders, care plan and standards of practices. This deficient practice had the potential to result in the development of pressure ulcer for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure appropriate discharge was provided for a one of eight residents (Resident 8). Resident 8 was discharged home, pending the result of the second Medicare appeal (a notice of discharged from the hospital or that other types of services will be discontinued) results filed with the Livanta (reviewers that conduct medical record review by following Medicare medical review standards for various beneficiary appeals related to the cessation of services, such as hospital discharges, termination of skilled nursing services, and other beneficiary appeals.) This deficient practice had the potential to result in resident's needs not being met at discharge and placed the resident's safety in jeopardy.

Inspectors wroteBased on interview and record review, the facility failed to develop a care plan for three of five sampled residents (Resident 2, Resident 4, Resident 5), who were exposed to the corona virus ([COVID-19]- an infectious virus that spreads from person to person and affects how a person breathes] infection. This deficient practice had the potential to place Resident 2, Resident 4 and Resident 5 at risk for COVID-19 infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure four of 14 sampled residents (Residents 54, 134, 66, and 31) medical records were initiated and/or updated to show documentation that Physician Orders for Life Sustaining Treatment (POLST- a form with written medical orders from a physician, nurse practitioner or physician assistant that helps give people with serious illnesses more control over their own care by specifying the types of medical treatment they want to receive during serious illness) and advance directives (a written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) were discussed and written information were provided to the residents and/or responsible parties. 1. [...]

Inspectors wroteBased on observation and interview the facility failed to ensure the nightstand table drawer easily opened and closed for one out of five Residents (Resident 34). This deficient practice had the potential not to meet Resident 34's needs.

Inspectors wroteBased on interview and record review the facility failed to ensure one out of five residents (Resident 134) had a physician order for isolation precautions. This deficient practice of not having a physician order for isolation precautions placed the Resident 134 at risk for having the incorrect protection against infection for the staff and other residents.

Inspectors wroteBased on interview and record review, the facility failed to implement a comprehensive care plans for one of two sampled residents (Resident 31). This failure had the potential for unmet care needs.

Inspectors wroteBased on interview and record review the facility failed to ensure one out of five Residents (Resident 134) had a revised care plan. This deficient practice of not revising the care plan for Resident 134 had the potential to spread infection to other Residents and Staff.

Inspectors wroteBased interview and record review, the facility failed to effectively manage a resident's pain for one of one resident, Resident 70 as evidenced by. 1. The facility staff failed to call the physician after Resident 70 experienced excruciating pain unrelieved by the pain medication administered as ordered by the physician. As a result, after ineffective pain management, Resident 70 was laid in the bed all night in pain.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that a licensed pharmacist performed a monthly medication regimen review (MRR- a thorough evaluation of the medication regimen of a resident to promote positive outcomes and minimize adverse consequences and potential risks associated with medication) for one of three sampled residents (Resident 10) reviewed for unnecessary medications. This deficient practice placed Resident 10 at risk of receiving unnecessary medications that could lead to significant medication-related adverse consequences (a harmful effect could by a medication).

Inspectors wroteBased on observation, interview, and record review, the facility failed to remove an unlabeled, expired bottle of Pedialyte (an oral rehydration solution) from the medication room located at Nursing Station 1. This deficient practice had the potential to cause harm to a resident. The unlabeled, expired Pedialyte had the potential to grow harmful bacteria which could cause food poisoning or other illness and could mistakenly be given to one of the residents.

Inspectors wroteBased on observation, interview, and product information review, the facility failed to maintain safe food handling practices. The facility failed to ensure frozen food products were labeled. This had the potential to result in foodborne illnesses in the highly susceptible resident population.

Inspectors wroteBased on observation and interview, the facility failed to implement infection control measures by failing to: 1. Ensure the facility's housekeeping aide performed hand hygiene after cleaning resident's rooms. 2. Perform appropriate hand hygiene while providing wound care treatment for one od one residents (Resident 15). 3. Change one of one sampled residents (Resident 66) oxygen tubing every seven days. These deficient practices had the potential to result in cross contamination of residents' environment, and the potential to spread microorganisms between the residents and the public.

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