La Crescenta Healthcare Center

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that food brought into the facility from outside was labeled and stored appropriately for one of one sampled Resident refrigerator in accordance with the facility's policy and procedure titled Food Brought from Outside the Facility. This failure had the potential to result in residents getting a foodborne illness such as food poisoning, since the food safety, freshness and ownership cannot be verified.

Inspectors wroteBased on interview and record review, the facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN, notice of transfer of potential financial liability usually paid by Medicare (a federal health insurance) but may not be paid for in this instance because it is not medically reasonable and necessary, or custodial care) to beneficiaries before the non-covered extended care items or services are provided by the facility for two of three sampled residents (Resident 3 and Resident 60) who were discharged from Medicare Part A and continue to live in the facility. 1. Resident 3 last covered day of Medicare Part A service was on 4/13/2026. 2. Resident 60 last covered day of Medicare Part A service was on 3/10/2026. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide oxygen therapy as ordered by the physician to one of one sampled resident (Resident 14), who was not receiving oxygen due to NC (a flexible tube with two prongs that rest in the nostrils to deliver supplemental oxygen) was in a bag attached to an oxygen concentrator (a machine that takes air from the surroundings, extract oxygen and filter it into purified oxygen). This deficient practice had the potential for Resident 14 not to receive adequate oxygenation that could lead to respiratory decompensation (when respiratory system fails to meet the body's oxygen and carbon dioxide needs, requiring immediate intervention like oxygen), shortness of breath (SOB) and respiratory distress.

Inspectors wroteBased on interview and record review, the facility failed to provide medically-related social services to one of five sampled residents (Resident 21) when the Social Service Designee (SSD) did not follow up to ensure Resident 21's Advance Directive (AD a legal document indicating resident preference on end-of-life treatment decisions) and DPOA ( Durable Power of Attorney) provided by the resident's responsible party (RP) was for a health care and not for financial in accordance with the facility's policy and procedure titled Advance Directives. This failure had the potential to result in Resident 21 receiving treatment against her wishes and placing Resident 21's safety at risk.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 85) did not store at the bedside that is accessible to other residents and visitor, and self-administer Albuterol Inhaler (medication used to quickly treat or prevent bronchospasms, including asthma symptoms (wheezing, tightness) and breathing difficulties) that was observed at Resident 85's bedside table in accordance with the facility's policy and procedure Medication Storage. Resident 85 stated, the Albuterol inhaler was given by her doctor and had been using it as needed every six hours when she had trouble breathing. Resident 85 did not have a Physician Order to administer the Albuterol inhaler. Resident 85 did not have an order for self-administration of the Albuterol inhaler. [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately document the code status (a medical order indicating what emergency treatments a resident wants or does not want if their heart or breathing stops) of one of five sampled residents (Resident 5) was for full code (in the event of the resident's heart stops beating or stops breathing, all life-saving measures such as CPR and intubation will be used to attempt to save a resident's life) in the resident's clinical record when Resident 5 chose selective treatments as indicated on the Physician Orders for Life-Sustaining Treatment (POLST actionable medical order signed by a doctor or medical provider that translates a seriously ill patient's end-of-life wishes). This failure had the potential to result in Resident 5 receiving treatment against her wishes.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Registered Nurse (RN) 3 performed hand hygiene for one of one sampled resident (Resident 50) after Registered Nurse (RN) 3 administered medications to Resident 50 via gastrostomy tube (GT) (a small tube placed through the belly directly into the stomach to provide nutrition, liquids, and medicines ) and then proceeded to administer eye drops (Artificial Tears) to Resident 50 on 5/7/2026. This deficient practice had the potential to transfer bacteria and/or virus (tiny germs that cause infections) from Resident 50's GT site to Resident 50's eyes.

Inspectors wroteBased on interview and record review, the facility failed to implement an antibiotic stewardship program (a coordinated program that promotes the appropriate use of drugs used to treat infections, including antibiotics) for antibiotic use when two of five sampled residents (Residents 61 and 89) did not meet criteria for antibiotic use and facility did not report it to the attending physician. This failure had the potential to result in residents receiving unnecessary antibiotics leading to antibiotic resistance (when bacteria evolve to survive and multiply despite the presence of antibiotic drugs designed to kill them). 1. [...]

Inspectors wroteBased on observation, interview, record review, the facility failed to ensure the call light was accessible and within reach for one of six sampled residents (Resident 14), who was dependent with all activities of daily living (ADL), visually impaired, and a high risk for fall as indicated in the resident's care plan and facility's policy and procedures titled Call Lights-Answering Of. This deficient practice had the potential to result in Resident 14 not able to call for assistance for ADL care, and in cases of emergency such as a fall with injury which can negatively affect Resident 14's quality of life.

Inspectors wroteBased on interview and record review, the facility failed to post accurate nurse staffing information of actual hours worked by Registered Nurses (RN), License Vocational Nurse (LVN) and Certified Nurse Aides (CNA) per shift on 5/7/26 in accordance with the facility's policy and procedure titled Posting Direct Care Staffing Numbers. This deficient practice of posting inaccurate nurse staffing information failed to ensure that residents, their representatives, visitors, and regulatory personnel had access to correct and reliable staffing data. This had the potential to misrepresent the actual number of nursing staff available to provide resident care and could negatively affect transparency and the facility's compliance with required posting regulations.

Inspectors wroteBased on interview, and record review, the facility failed to provide a safe and secured environment for one of five sampled residents (Resident 1), reviewed for accidents/safety, who was identified at risk for elopement (when a person with cognitive [thought process] impairment leaves a safe area, such as a care facility or home, without awareness of the potential dangers), wandering (a person that roams around and becomes lost or confused about their location) out of the facility, and at risk for falls by failing to: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents reviewed for accidents/hazards received adequate supervision to prevent accidents and injury for one of two sampled residents (Resident 1), who had a recent fall, and who was identified at high risk for falls upon admission on [DATE], by failing to:1. Ensure the facility communicated and provided awareness to licensed nurses (Licensed Vocational Nurse [LVNs 1 and 2] and Registered Nurse [RN] 1) and certified nurse assistants (CNAs 1, 2, 3 and 4) that Resident 1 was identified as high risk for falls due to recent history of falls history of falls and interventions to visually monitor every hour, in accordance with the care plan for falls and the physician order.2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy for Medication Pass Guidelines and the professional standard of practice for one of one sampled resident (Resident 49) who received his scheduled 9 AM medications more than one hour late. This deficient practice had resulted in Resident 49, who also receives medication to lower blood pressure, felt frustrated, and had the potential for Resident 49 to have elevated blood pressure and not to optimize the effect of his drug therapy that could negatively affect Resident 49's quality of life Findings. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility's waste dumpsters cover were kept closed and not exposed to elements in the trash area. This failure had a potential to result in pest infestation [an increase in the numbers of a pest species (insect or small animal that is harmful, such as rats, mice, or cockroaches) in a given area], odors, unsanitary environment, and a spread of bacteria (small living things that could be dangerous and cause illnesses) and insects (small animals such as ants, and flies).

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the facility ' s policy for Infection Control Program and Hand Hygiene for six of 16 sampled residents ' (Resident's 57, 35, 30, 66,41, and 64) during dinning observation in the Front Dining Room (FDR) by failing to ensure: 1. The Activity Director (AD) who was observed serving, preparing food trays and touching Resident's 57, 35 and 30 without performing hand hygiene before and after direct contact. 2. Director of Staff Development (DSD) was observed serving, preparing food trays and touching Resident's 66, 41 and 64 without performing hand hygiene before and after direct contact. This deficient practice had the potential to cause and/or spread infection (a process when a microorganism, such as bacteria, fungi, or a virus, enters a person's body and causes harm) in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the facility ' s dishwasher in operating condition to keep in a safe and efficient manner when the dishwasher failed the chlorine sanitizer (an effective, chlorine-based, substance or product used to reduce the number of harmful germs on all food contact surfaces to a safe level when cleaned and processed through an approved ware wash operation) test on 4/22/2025 at 9:05 AM. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow the facility ' s policy and procedure for self-administration of medications for one out of one sampled resident (Resident 75) when: 1. Resident 75 was not assessed prior to self-administration of medications. 2. Resident 75 was observed storing medications at the bedside. This deficient practice had the potential for Resident 75 and other resident who can have access to the medications to be at risk of harm from potential side effects or adverse effect (undesired effect of medication) that the medications could pose on Resident 75.

Inspectors wrote2. A review of Resident 33's admission Record, indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia (a gradual decline in mental ability usually caused by a brain disease), Parkinson's disease a brain disorder in which there is a lack of the chemical messenger dopamine, which helps control muscle movement; leads to muscle stiffness, weakness, and trembling), and osteoarthritis (inflammation of the joints due to the breakdown of the cartilage lining the bones in joints). A review of Resident 33's H&P, dated 11/27/2024, indicated the resident has a history of fractures (a break in a bone). The H&P also indicated the resident has a history of mental illness. A review of Resident 33's MDS, dated [DATE], indicated Resident 33 has severely impaired cognition (the ability to think and process information). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan to address Resident 32's refusal to have the long nails with fungal infection and for podiatric (a physician specialized in foot treatment) treatment on 7/13/2024, 8/24/2024, 10/24/2024 and 1/7/2025 (total 4 days). This deficient practice had a potential result in Resident 32's inadequate and incomplete provision of care and result in worsened foot infection and pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care and treatments in accordance with the professional standards of practice, care plan goals, physician's order and the facility's policy and procedure for one of one sample residents (Resident 78) who was observed without oxygen for more than 30 minutes, while pulse oximeter reading (a measure of how much oxygen is carried by red blood cells in the blood, expressed as a percentage, with a normal range being 95-100%) decreased to 85%. The Physician ordered Resident 78 to receive oxygen at 2 liters (standard unit used to measure the rate of oxygen flow) as needed for shortness of breath or oxygen saturation less than 93 percent. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication error rate of five percent or (5%) or less during medication pass for two of four residents (Residents 28 and 237) in which three (3) medication errors were identified out of 30 opportunities which yielded a cumulative error rate of 10 %. Licensed Vocational Nurse (LVN) 1 checked the heart rate of Resident 237 prior to the administration of Hydrochlorothiazide (medication that lowers the blood pressure and heart rate) and Verapamil (medication ordered to manage hypertension [HTN- elevated blood pressure]) LVN 1 verified the dosage of Cyanocobalamin B12 (a vitamin supplement) according to the physician's order, the Medication Administration Record (MAR) and the medication available prior to administration of of to Resident 28's.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four observed residents (Residents 237) was free from any significant medication errors when Licensed Vocational Nurse (LVN) 1 did not check the heart rate of Resident 237 prior to the administration of Hydrochlorothiazide (medication that lowers the blood pressure and heart rate) and Verapamil (medication ordered to manage hypertension [HTN- elevated blood pressure]). This deficient practice had the potential for the resident have dangerously decreased blood pressure and heart rate that could result in hospitalization and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedure for medication storage when one out of three medication carts was found to have 2 insulin pens (medication to control the blood sugar), belonging to Resident 72, that were not discarded within 28 days from the opened date. This deficient practice had the potential for staff to administer the insulin pens, which may less efficacy and could lead to the mismanagement of the blood sugar of Resident 72.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nutritional supplement and food products for two out of three stored in the medication carts were labeled with expiration date, in accordance with the facility's policy and procedure. This deficient practice had the potential for facility staff to administer the food products to residents, which could cause foodborne illnesses (a disease caused by consuming contaminated food or beverages. These contaminations can be from bacteria, viruses, parasites, or harmful chemicals that can cause nausea, vomiting, diarrhea, and fever).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure prompt attempts were made to resolve grievances brought by resident representative (Family [FM] 1) for one of three sampled residents (Resident 1) to the facility, and reports/resolution was signed and made available to the resident or FM 1, in accordance to the facility policy and procedure (P&P) titled Grievances and Complaints. This deficient practice violated the resident ' s right to have their grievance properly addressed and resulted in care that did not align with the resident ' s wishes/preferences.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement the resident ' s care plan to wear protective clothing and/or Geri sleeves to protect skin due to pinching/scratching self and/or when agitated for one of three sampled residents (Resident 1). This deficient practice may have the potential to compromise quality of life, unmet care needs, increased risk of health decline and emotional and psychological distress.

Inspectors wroteBased on interview, and record review, the facility failed to meet professional standards of quality for one of three sampled residents (Resident 3) by failing to ensure medications were administered by licensed personnel only, in accordance the facility policy and procedure (P&P) titled Medication Pass Guidelines. This deficient practice had the potential to result in serious harm, including the risk of injury to the resident due to medication errors that could have occurred.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a person-centered care plan with individualized interventions that included the dementia (a disorder of mental processes caused by brain disease or injury and marked by memory disorder, Personality changes, and impaired reasoning) care needs with behavioral issues for one of three sampled residents (Resident 1), in accordance with the resident ' s care plans written for dementia and ADL functional /Rehabilitation and the facility ' s policy & procedures (P&P) titled Behavioral Symptoms Associated with Dementia Management. Resident 1 manifested increased in behavior/agitation when care was rendered by registry staff of certain ethnicity as requested and repeatedly filed through the facility ' s grievance process. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow the prescribed diet order for one of three sampled residents (Resident 1). Resident 1, who is on a very low- carbohydrate, double protein, 1200- calorie diet, did not receive meals in accordance with correct order and prescribed portion sizes. This deficient practice resulted in an unintentional weight gain (not on purpose) , potentially delaying recovery from illness or injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a personal safety alarm (PSA: any physical or electronic device that monitors resident movement and alerts the staff when movement is detected) was placed on one of two sampled residents (Resident 1) bed, who was assessed as a high risk for fall, in accordance to the facility ' s policy and procedure (P&P) titled, Personal Safety Alarm. This deficient practice had the potential for a delayed response from facility staff when Resident 1 attempted to get out of bed unassisted, potentially resulting in falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect and promote resident rights for 1 of 3 sampled residents (Resident 1) when LVN 1, CNA 2, and CNA 3, continue to change Resident 1 ' s diaper after Resident 1 refused to be changed. This deficient practice resulted in Resident 1 ' s right hand accidentally hit the bedrail (metal or plastic bars positioned along the side of a bed, also commonly known as side rails) and caused bruising (an injury in which the skin is not broken but is discolored from the breaking of small blood vessels that lie underneath the skin) to the back of the right hand and right wrist area.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food tray was served timely for one of three sampled residents (Resident 4) when Resident 4, who was in the dining room, lunch tray was delivered at 1:00 P (scheduled meal service was 12:15 PM). This deficient practice had the potential to affect the palatability of the food (quality of being tasty or acceptable in some other way), attractiveness and temperature which could decrease food intake and affect Resident 4 ' s nutritional health (the adequate provision of vitamins, minerals, fiber, water carbohydrates, proteins, fats and other micronutrients to cells and organisms, to support life).

Inspectors wroteBased on interview and record review the facility failed to report immediately, but not later than 2 hours, all alleged violations involving abuse, including injuries of unknown source to the California Department of Public Health for one of three sampled residents (Resident 1) with increased bruising on the left flank area and new fractures of the ribs on 6/1/24. This deficient practice had the potential for Resident 1 and other residents in the facility to be subject from possible abuse in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose garbage and refuse (food waste, scraps) properly by not covering three of three metal dumpsters (large trash container designed to be emptied into a truck) due to overflowing garbage bags leaving more than 5 trash bags, broken sofa, broken chair, and boxes on the ground next to the dumpster. This deficient practice had a potential to attract birds, flies, insects, pest and possibly spread infection to 87 of 87 facility residents and staffs in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure an Advance Directives (AD-a written statement of a person's wishes regarding medical treatment to ensure those wishes are carried out should the person be unable to communicate his/her needs to the doctor) and the Physician Orders for Life-Sustaining Treatment (POLST: medical order forms that indicate to the medical staff what to do in an event of medical emergency) were offered and/or obtained and accessible in the residents medical records for 4 of 5 sampled residents (Resident 187, 30, 25 & 74). The facility failed to ensure: 1. Resident's 187 Advance Directive acknowledgement form was not located in the paper chart and POLST was not completed. 2. Resident's 30, 25, and 74 medical records did not include and Advance Directive acknowledgement form. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to provide treatments and services for three out of six sampled residents (Residents 68, 25, and 17) at risk for decline in range of motion (ROM, full movement potential of a joint) and mobility by failing to: 1a. Provide Resident 68 with Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) treatments for passive range of motion (PROM, movement at a given joint with full assistance from another person) exercises on both lower extremities (BLE, hip, knee, ankle, feet) five (5) times a week as ordered. 1b. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to insure resident's safety through implementation and fire prevention interventions. by identifying and eliminating fire and environmental hazard for two of twelve sampled residents (Residents 35 and 288) by failing to ensure heating units ( a machine used that provide heat in the room) were free and clear of potentially flammable ( materials that can cause fire) items. This deficient practice had a potential to result in a fire that could lead to burns, injury and death to the facility staffs, residents and visitors.

Inspectors wroteBased an observation, interview and record review, the facility failed to: 1. Ensure the activities recorded in the Controlled Drug Records (the accountability record or count sheet for narcotics) had corresponding administration documentations in residents' electronic medication administration records (eMAR) for two (2) of 29 sampled residents (Residents 46 & 64). 2. Ensure there was a policy, developed and implemented, for the accurate usage of the Emergency Medication Supplies (E-kit). There were missing entries in the E-kit logbook. These deficient practices had the potential for drug diversion (medical and legal concept involving the transfer of any legally prescribed controlled substance from the individual for whom it was prescribed to another person for any illicit use) and/or medication errors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (1) of 3 medication carts were locked when left unattended in the hallway. Registered Nurse 2 (RN2) prepared the medication and did not lock the medication cart before entering the resident ' s room. These deficient practices had the potential to result in misuse or medication loss by providing the unauthorized staff or person an opportunity to access resident ' s medications.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the kitchen staff were routinely trained and evaluated for competency and skills sets to carry out functions of the food and nutrition service by failing to: a. Staff failed to demonstrate and verbalize the correct procedures in testing the chlorine (a chemical used for disinfectant) for low temperature dish machine. b. Staff failed to verbalize and follow the manufacturer ' s guidelines of QT-40 test strips (a type of test strip) when checking the Quaternary Ammonium Compounds (Quats, a group of chemicals used to disinfect surfaces and equipment) sanitizer concentration. c. Staff failed to verbalize proper cooling procedures of food. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow the menu for 32 of 85 residents on Regular texture diet (diet that has no restriction in texture and consistency) by not following the portion size for paprika chicken based on the facility ' s menu spread sheet. This deficient practice placed the facility residents at risk of unintended (not done on purpose) weight gain or weight loss and not meeting the physician ' s diet orders causing delay of recovery from illness or injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen in accordance with the facility ' s policy and procedure and standard of practice by failing to ensure: 1. Equipment and kitchen cleanliness were maintained: a. Three of 3 storage racks had rust-looking discoloration and stained in the walk-in refrigerator. b. Storage rack where bananas were stored in the preparation area had dust and dirt buildup. c. Storage container for ketchup, mix jelly, creamer and yellow cake mix had food and dirt residue. d. Dry storeroom floors had dirt debris. e. Kitchen hood had grease and dirt buildup. f. Three of 3 vent by the tray line area (food preparation area in which food trays travel around the production line) had dirt buildup. 2. Ensure measures to prevent cross-contamination was maintained: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain an informed consent for psychotropic/psychotherapeutic (any drug that affects behavior, mood, thoughts, or perception) drugs for one of one sampled resident (Resident 39) who was prescribed Sertraline (medication used to treat depression [a persistent feeling of sadness and loss of interest]), and Divalproex (medication used to treat certain types of seizures (epilepsy) and mood disorder (a disorder manifested by severe feeling of sadness and no interest with ADLs [activity of daily living]). This deficient practice had violated Resident 39 ' s rights to be informed and choose the type of care or treatment to be received, make decisions on alternative measures the resident or responsible party preferred, which can negatively affect Resident 39 ' s quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodations of need for resident needs and preferences for 2 out of 22 sampled residents (Resident 22 and 35) by not ensuring the overhead light cord was within resident (22 and 35) ' s reach that prevented resident 22 and 35 from having the ability to turn the light on or off as needed. This deficient practice is not in line with the resident ' s right to have adequate lighting and reasonable accommodation of needs and preferences which limits the resident's ability to see clearly and adjust the lighting to their individual needs. In addition, this deficient practice could also result in accident that results in injury to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate lighting suitable to perform tasks that the resident chooses to perform, or the facility staff must perform to assist one of twenty-two sampled residents (Resident 48). This deficient practice violated the resident ' s right to reasonable accommodation of needs and preferences which was essential to creating and individualized, home- like environment to include adequate and comfortable lighting levels. This deficient practice could also result in resident falls or accidents in the room which could lead to injury. Comfortable light means lighting that minimizes glare and provides maximum resident control, where feasible, over the intensity, location, and direction of lighting to meet their needs or enhance independent functioning.

Inspectors wroteBased on interview and record review the facility failed to develop an individualized resident-centered care plan (a care plan that prioritizes the unique health needs and desired outcomes of the resident) to meet the resident's' needs for two of 2 sampled residents (Resident 17 and Resident 187). 1. Resident 17 did not have a care plan with a measurable objective to ensure the resident is participating in activities. 2. Resident 187 was unable to attend group activity. The care plan did not indicate the reason the resident was unable to attend activities. The care plan goals indicated Resident 187 will benefit and participate in room/bedside activities: X/week. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide necessary care and services to one of three sampled residents (Resident 46) who was dependent with the staff to carry out activities of daily living (ADL) by not maintaining grooming, and good personal hygiene by not shaving her long facial hairs above the lips and under the chin. This deficient practice had the potential to negatively affect Resident 46 ' s self image, physical appearance, dignity, and quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide sufficient hydration to one of 2 sampled residents (Resident 22) who was not provided and offered water at bedside to maintain and promote proper hydration (process of replacing water loss in the body) and health as indicated in resident ' s care plan. This deficient practice had the potential to place the resident at risk for dehydration (a harmful reduction in the amount of water in the body) and poor nutritional outcomes.

Inspectors wroteBased on observation, interview, record review, the facility failed to ensure a call light (a device that allows residents to signal caregivers when they are in need of help and allows caregivers to communicate with each other at a distance) was accessible while in bed for one of five sampled residents (Resident 39) who was observed with call light stuck between the left side bedrail and the bed, hanging below the bottom of the mattress. Resident 39 stated she needed assistance from the staffs because she was having difficulty putting her sweater and she was feeling cold and unable to reach the call light to call for assistance. This failure had the potential for Resident 39 not to receive assistance timely or not receive assistance with her needs or in an event of an emergency that could result in a decline in performing ADLs (activities of daily living) residents well being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to place fall risk identifiers for one of three sampled residents (Resident 1) in accordance with the facility ' s policy and procedure (P&P). This failure had the potential to result in repeated falls for Resident 1 who already had a history of multiple falls with injury. Findings During a review of Resident 1 ' s admission record, the admission Record indicated the resident was originally admitted to the facility on [DATE], with diagnoses that included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), hypertension (high blood pressure), hyperlipidemia (excess of fats in the blood), and atrial fibrillation (abnormal heartbeat that can lead to blood clots in the heart). [...]

Inspectors wroteBased on observation, interview, record review, the facility failed to ensure the call light was within reach, as indicated in the care plan for fall and dementia, and in accordance with the facility's policy for falls and call lights for one of two sampled residents (Resident 1). This failure had the potential to negatively affect Resident 1 ' s quality of life and quality of care for not being able to call for assistance if needed. Resident 1 had diagnoses that include dementia and anxiety disorder. Resident 1 was a fall risk and had a fall incident on 10/24/23. Resident 1 had been diagnosed with osteoporosis ( decrease in bone strength that can increase the risk of fractures) and had an injury of unknown origin on 11/06/23 Left Hip Fracture (Break). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents, who were at risk for falls and history of multiple falls, had assigned direct care staff that were made aware of revisions to the resident ' s fall care plan by failing to: 1. Ensure Resident 1 ' s fall care plan initiated on 9/20/23 and revised on 10/21/23 was implemented to include staff visual monitoring every hour for fall precaution. 2. Include Resident 1 on the list of residents for CNA3 to monitor. 3. Orient CNA3 on Resident 1 ' s history of falls and fall interventions to be implemented. 4. Ensure CNA3 would monitor Resident 1 as part of general fall prevention and not only when out of bed and in the Activity Room. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 2) was free from sexual abuse (non-consensual sexual contact) on 9/22/2023 around 2 PM when Resident 1 exposed his penis (the male genital organ) and grabbed Resident 2 ' s breast while in the facility ' s Activity Room as observed by Resident 3. These deficient practices resulted in Resident 2 experiencing sexual abuse and unwanted nonconsensual sexual contact from Resident 1. [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to report allegations of sexual abuse from another resident to the State Agency (California Department of Public Health [CDPH]) and other officials immediately, but not later than two hours, in accordance with the facility ' s policy and procedure on Abuse Investigation and Reporting Policy and Procedure, for one of three sampled residents (Residents 3). Resident 3 and Family Member (FM 1) reported to facility staff (Receptionist [RCP]) that Resident 1 was observed exposing his penis (the male genital organ) and grabbing Resident 2 ' s breast while in the facility ' s Activity Room on 9/23/2023. [...]