La Palma Nursing Center

Inspectors wroteBased on interview and closed medical record review, the facility failed to honor the resident's wishes to withhold life-sustaining measures, including CPR, in the event of cardio-pulmonary arrest as documented in the POLST (Physician Orders for Life-Sustaining Treatment) for one of three sampled residents (Resident 1) reviewed for resident rights. * Resident 1 had a physician's order for Do Not Attempt Resuscitation/DNR. The facility provided CPR (Cardiopulmonary Resuscitation) to Resident 1 when the resident became unresponsive and without a pulse. This failure had the potential to result in physical and psychological harm to the resident.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to maintain safe water temperature levels in 5 of 5 rooms tested for the water temperature. * The water temperatures were measured to read between 130.5 to 134 degrees Fahrenheit, when the normal temperature ranges were 105-120 degrees Fahrenheit. * The facility failed to provide education to the direct care staff regarding safe water temperature. These failures had the potential to cause severe burn injury to the residents and staff of the facility not to be aware of the safe water temperature.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the residents were not allowed to have and self-administer the medication(s) found at the bedside for two nonsampled residents (Residents 35 and 78) who were not able to safely administer their own medications based on their self-administration assessment. * Resident 35 was assessed and determined not safe to self-administer her medications. However, Resident 35 had a bottle of Advil (NSAID, nonsteroidal anti-inflammatory drug) medications at the bedside and was self-administering the medication. Additionally, there was no physician's order and care plan problem addressing the resident's self-administration of the medication. * Resident 78 was assessed and determined not safe to self-administer his medications. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure three of five sampled residents (Residents 9, 11, and 34) reviewed for unnecessary medications were free from unnecessary medications. * The facility failed to ensure Resident 9 was monitored for adverse events such as orthostatic hypotension related to the use of psychotropic medications. Resident 9 had a physician's order for sertraline (medication used to help improve mood) and Depakote (anticonvulsant). * The facility failed to ensure Resident 11's documentation of meal intake was accurate to identify when the resident had a meal intake of less than 50% and failed to complete the monthly behavior summary related to the use of mirtazapine (antidepressant). * The facility failed to ensure Resident 34's order for Depakote medication showed the specific behavior targeted by the medication. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure an injury of unknown origin was thoroughly investigated for one final sampled resident (Resident 34) investigated for injury of unknown origin. * There was no investigation conducted for Resident 34's skin discolorations on the left mid breast and upper backside. This failure resulted in a delay of identifying and investigating the cause for injury, with the potential to expose the resident to further injury or abuse.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide services to attain or maintain the highest practicable well-being for one of 17 final sampled residents (Resident 5). * The facility failed to clearly identify the current code status for Resident 5. This failure posed the risk of confusion, delay in the provision of care in accordance with the resident's treatment wishes.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of 17 final sampled residents (Resident 3) who required hearing aids received the proper treatment and assistive device to maintain her hearing abilities. * The facility failed to ensure Resident 3's right and left hearing aids were applied as ordered by the physician. In addition, the facility failed to ensure the necessary actions were taken when Resident 3's left hearing aid was missing since February 2025 per the resident's responsible party. This failure had the potential for the resident to not clearly hear, understand, and make appropriate responses to the conversations.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the necessary GT care and services for one nonsampled resident (Resident 16). * The facility failed to ensure Resident 16's head of the bed was elevated to at least 30 degrees while the GT feeding was infusing. This failure posed the risk for Resident 16 developing complications related to Resident 16's GT such as aspiration which can lead to aspiration pneumonia and respiratory compromise.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure three of six final sampled residents (Residents 2, 3, and 5) remained free from accident hazards due to the use of the side rails. * The facility failed to ensure the less restrictive interventions were completed prior to the use of the right grab bar for Resident 2. * The facility failed to ensure the less restrictive interventions were completed prior to the use of the bilateral grab bars for Resident 3. * The facility failed to ensure less restrictive measures were provided prior to the use of the right grab bar for Resident 5. These failures had the potential for the residents to receive the unnecessary grab bars and could put the residents at risk for entrapment and serious injuries.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary pharmacy services for one of 17 final sampled residents (Resident 47), one nonsampled resident (Resident 13), one of five residents (Resident 34) reviewed for the unnecessary medications, and in one medication room (Medication room [ROOM NUMBER]). * The facility failed to clarify the order with the physician for the administration of the rapid acting insulin to Resident 34. * The facility failed to ensure Resident 47's tramadol (a controlled medication for pain) was accurately and appropriately unaccounted for. * The facility failed to ensure the multiple hydrocodone/ acetaminophen 5-325 mg (a controlled medication for pain) tablets removed from the supply were administered and documented in Resident 13's MAR. [...]

Inspectors wroteBased on interview, medical record review, and facility document review, the facility failed to ensure one of five final sampled residents (Resident 34) reviewed for unnecessary medications received appropriate pharmacological recommendations. * The facility's Pharmacist Consultant failed to make recommendations based on Resident 34's elevated hemoglobin A1c (a blood test that measures the average blood sugar (glucose) level over the past 2-3 months) results and insulin use for diabetic management. This failure had the potential for the resident's diabetic regimen not being promptly re-evaluated by the physician.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure two of five final sampled residents (Residents 3 and 34) reviewed for unnecessary medications were free from the unnecessary medications. * The facility failed to ensure Resident 3 was monitored for signs and symptoms of bleeding for the use of clopidogrel bisulfate (medication used to prevent dangerous blood clots). * The facility failed to ensure Resident 34 was monitored for bleeding related to clopidogrel bisulfate medication use. These failures had the potential for the residents to receive unnecessary medications and develop significant adverse effects.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 39.29%. Two of two licensed nurses (LVNs 2 and 3) were found to have made errors during the medication administration. * Resident 10 had a physician's order for metoprolol (antihypertensive medication) with parameter to hold if HR (heart rate) is less than 60 beats per minute (bpm). LVN 3 failed to check the resident's HR prior to administering the medication. In addition, Resident 10 did not receive the full dose of vitamin D3 (supplement) and Rena Vite (supplement) medications when there was residual left in the medicine cups after LVN 3 administered the medications via GT. * LVN 2 failed to ensure seven medications were not left in pill pouches used for crushing Resident 62's medications. [...]

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. * The facility failed to ensure two plastic containers with clean scoops were free from dust and dry food crumbs. * The facility failed to ensure safe storage of food items. * The facility to ensure complete hair restraint was done by the dietary staff inside the kitchen. * The facility failed to ensure Resident 47 did not store food from the kitchen at the bedside. These failures had the potential to cause foodborne illness for residents who consumed food prepared in the kitchen.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the P&P was followed regarding outside food brought into the facility for one nonsampled resident (Resident 76). * There were unlabeled food items observed at Resident 76's bedside. * The facility failed to ensure the staff, residents, and/or their responsible party were educated on safe food handling guidelines. These failures had the potential to expose the residents who received food brought from the outside to food borne illnesses.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to implement the infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of diseases and infections. * The facility failed to maintain an accurate infection control surveillance program for August 2025 when the IP classified the infections as CAIs, HAIs, and those who did not meet the McGeer Criteria. In addition, the facility failed to ensure the monthly infection surveillance mapping included all infections in the facility. * The facility failed to ensure the residents' blankets, wedge pillows, and splints in the laundry area were stored in a clean and sanitary manner. * CNA 7 failed to wear a gown when providing care and changing the linens for Resident 16 who was on EBP precaution. [...]

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the regular inspection for all the facility beds was conducted as part of the regular maintenance program. * The facility failed to conduct a regular inspection of Residents 2, 3, and 5's beds, bed frames, and mattresses, as part of the regular maintenance program. These failures had the potential to compromise residents' safety, health, and well-being.

Inspectors wroteBased on interview, medical record review, and facility's P&P review, the facility failed to obtain and maintain a copy of the advance directives (a legal document stating a person's wishes about receiving medical care if the person is no longer able to make medical decisions) for two of four final sampled residents (Residents 8 and 33) reviewed for the advance directives. * The facility failed to inquire about the existence of an advanced directive for Resident 8. * The facility failed to maintain a copy of Resident 33's advanced directive in the resident's medical record. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the necessary transfer/discharge services for one of two final sampled residents (Resident 51) reviewed for acute care hospitalization. * The facility failed to notify Resident 51 and/or their representative in writing regarding the transfer and reasons for the transfer, and the facility's bed hold policy when Resident 51 was transferred to the acute care hospital. This failure had the potential for the resident and/or their representative to be unaware about the transfer and reason(s) of transfer, and their rights to request a bed hold and return to the first available bed should the resident's acute care hospital stay exceed the seven-day bed-hold period.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the MDS assessment for significant change was completed timely for one of three residents (Resident 4) reviewed for closed records. * The facility failed to ensure the MDS assessment was completed in a timely manner when Resident 4 was admitted to the hospice services. This failure had the potential for the resident to not receive the necessary care and services based on the resident's assessment and needs.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the PASRR (Preadmission Screening and Resident Review) screening for one of five final sampled residents (Resident 9) reviewed for the unnecessary medications was accurately completed as per the facility's P&P. * The facility failed to complete a PASRR when the initial screening had inaccurate information indicating Resident 9 had no serious mental illness diagnosis. In addition, the facility failed to timely resubmit the required new Resident Review. This failure had the potential for the resident not to be screened accurately/timely and receive the necessary additional services if needed.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to develop and implement a comprehensive person-centered care plan for three of 17 final sampled residents (Residents 3, 9, and 34). * The facility failed to ensure the care plan showed specific monitoring for signs and symptoms of bleeding related to the use of clopidogrel bisulfate (medication used to prevent dangerous blood clots) for Resident 3. * The facility failed to ensure the care plan included the monitoring of orthostatic hypotension related to the use of the psychotropic medications for Resident 9. * The facility failed to ensure a care plan was developed for anticoagulant monitoring for Resident 34. These failures had the potential to cause inconsistent, inappropriate, and inadequate plans of care for the residents in a vulnerable population.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to revise the resident centered care plan for one of six final sampled residents (Resident 54) reviewed for accidents. * The facility failed to revise Resident 54's care plan when Resident 54 had a fall and the facility added new interventions for safety. This failure had the potential for the resident's to not receive the necessary care and services.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the appropriate care and services for one of two final sampled residents (Resident 11) with an indwelling urinary catheter. * The facility failed to consistently monitor the amount of Resident 11's urinary output related to catheter use as per the physician's order. In addition, the facility failed to monitor the 24-hour total, and weekly evaluation of Resident 11's average intake and output. These failures posed the risk for the resident to have fluid imbalances resulting in kidney damage or heart failure, inadequate hydration leading to infection, and delayed detection of CAUTIs or catheter obstruction which could lead to sepsis and death.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure the proper storage of medications. * The facility failed to ensure two opened and used vaginal creams labelled with an open date of 8/19 and 8/28/24, were properly stored. The medications were kept in the medication room together with floor stock medications. This failure had the potential for infection to the residents and potentially result in inappropriate administration of prescription medication.

Inspectors wroteBased on observation and interview, the facility failed to ensure the garbage and refuse were properly stored in three of four garbage dumpsters. * The lids of the facility's garbage dumpsters were partially (approximately one and half inch or two inch) open. This failure had the potential to harbor pests or rodents which carry diseases.

Inspectors wroteBased on interview, medical records review, and facility P&P review, the facility failed to ensure the medical records were complete and accurate for two of four residents (nonsampled Residents 62 and 63) observed for medication administration, one of one final sampled residents (Resident 23) reviewed for the hospice, and one of one final sampled residents (Resident 51) reviewed for acute care hospitalization. * The facility failed to document the medication administration and monitoring in Resident 62's MAR on 9/5 and 9/8/25. * The facility failed to document the medication administration in Resident 63's MAR on 9/5 and 9/8/25. * The facility failed to ensure an updated POLST was available in the medical record when Resident 23 formulated an advance directive. * The facility failed to document the interventions provided when Resident 51 had a low oxygen saturation. [...]

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of three sampled residents (Resident 1) received the necessary care and services to prevent accident hazards. * The facility failed to thoroughly investigate and document Resident 1's subacute closed fracture (a broken bone that has started to heal and is not breaking the skin) of multiple ribs of the left side. In addition, the facility failed to request the physician to complete the fracture progress report and failed to conduct the root cause analysis by IDT as per the facility's P&P when the subacute fracture of Resident 1's left multiple ribs was identified after the fall incident. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive care plans were developed to reflect the individual care needs for 13 of 16 final sampled residents (Residents 15, 17, 20, 32, 33, 34, 35, 40, 44, 45, 48, 59, and 366). * The facility failed to ensure the comprehensive person-centered care plans for the use of grab bars were in place for Residents 15, 17, 20, 32, 33, 34, 35, 40, 44, 45, 48, 59, and 366. This failure had the potential for residents to not be provided with appropriate, consistent, and individualized care.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure 13 of 16 final sampled residents reviewed for side rail use (Residents 15, 17, 20, 32, 33, 34, 35, 40, 44, 45, 48, 59, and 366) remained free from the accident hazards associated with the use of elevated side rails. * The facility failed to ensure the accurate and complete assessments and evaluations for the grab bars use for Residents 15, 20, 32, 33, 34, 35, 40, 44, 45, 48, 59, and 366. This failure had the potential to put the residents at risk for entrapment and serious injuries.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the cutting boards were kept in a sanitary condition and with cleanable surface. * The facility failed to ensure the scoops used for food portioning were air dried and clean prior to storing. * The facility failed to ensure the kitchen utensils had a smooth cleanable surface and were in good conditions. * The facility failed to ensure the kitchen utensils were clean and free of food particle or residue. * The facility failed to ensure the heavy-duty blenders used for puree preparation, the clear measuring containers, and the pink plastic drinking cups were air dried prior to storing. [...]

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the residents' entrapment assessments were accurate and complete for 13 of 16 final sampled residents (Residents 15, 17, 20, 32, 33, 34, 35, 40, 44, 45, 48, 59, and 366) reviewed for grab bar use. This failure had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one nonsampled resident (Resident 28) was provided with the necessary care in the manner that promoted dignity and respect. * The facility failed to ensure an effective communication with Resident 28 in a language understood by the resident. This failure had the potential to negatively impact the resident's emotional well-being, and risk for not providing the appropriate treatment of Resident 28.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the psychotropic medication informed consent for one of 16 final sampled residents (Resident 366) was signed by the physician. This failure posed the risk for Resident 366 to not be informed of their care and treatment for the psychotropic medication use.

Inspectors wroteBased on observation, interview, medical record, and facility P&P review, the facility failed to determine if it was safe for one of 16 final sampled residents (Resident 316) to safely self-administer the medications. This failure had the potential for Resident 316 to administer the medications inaccurately.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide reasonable accommodation to meet the needs of one nonsampled resident (Resident 60). * The facility failed to ensure the call light button was within Resident 60's reach. This failure had the potential to hinder Resident 60's ability to communicate with facility staff.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one nonsampled residents (Resident 43) had copy of her advance directive in her medical record. This failure had the potential for the resident's decisions regarding her healthcare and treatment options to not be honored.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the recommendations from the Preadmission Screening and Resident Review (PASARR, a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) Level II determination was followed up and incorporated into the resident care for one of one final sampled resident (Resident 44) reviewed for PASARR. This failure had the potential for Resident 44 not receiving the adequate care and services that were recommended by PASARR Level II determination and evaluation report assessed by a appropriate state-designated authority.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care for three of 16 final sampled residents (Residents 15, 34, and 59) and one nonsampled resident (Resident 55). * The facility failed to ensure Resident 55 was administered the oxygen as per the physician's order. This failure posed the risk to negatively affect Resident 55's medical condition. * The facility failed to ensure Resident 15's oxygen tubing was dated. * The facility failed to ensure the oxygen tubing was placed in a clear plastic bag when not in use and the nebulizer tubing were not touching the floor for Resident 34. * The facility failed to ensure accurate documentation of the monitoring of Resident 59's oxygen saturation level on room air. [...]

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the DHPPD nurse staffing forms were accurately posted as per AFL (All Facility Letter) 18-27. This failure had the potential to result in inaccurate staffing information provided to the public.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the pharmaceutical services to ensure accurate reconciliation, and disposal of medications. * The facility failed to ensure administration of the controlled medication for Resident 66 was documented in the controlled drug record and MAR. * The facility failed to ensure non-controlled medications were discarded by two licensed nurses. These failures posed the risk for diversion of medications.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure three of five residents reviewed for unnecessary medications (Residents 15, 36, and 44) were free from the unnecessary psychotropic medications. * The facility failed to ensure a specific behavior manifestation was identified for Resident 15 related to the use of divalproex (antipsychotic medication). The facility failed to ensure accurate monitoring for Resident 15's orthostatic blood pressure (measurement of the blood pressure while laying down and sitting) as ordered by the physician related to the use of an antipsychotic medication, when the blood pressure readings for Resident 15 had the same results for sitting and lying. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 7.14%. One of two licensed nurses (LVN 5) who were observed during the medication administration was found to have made errors. * LVN 5 failed to administer the metoprolol (antihypertensive medication) and diltiazem (antihypertensive medication) as per the physician's order when LVN 5 failed to ensure Resident 16's heart rate was taken prior to administering the medications. This failure had the potential for Resident 16 to develop significant side effects from the medications and affect Resident 16's health condition.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review the facility failed to ensure one nonsampled resident (Resident 16) was free from the significant medication error. * The facility failed to ensure Resident 16's heart rate was taken prior to administering the metoprolol (antihypertensive medication) and diltiazem (antihypertensive medication) medications. This failure had the potential to cause Resident 16 to have abnormally slow heart rate and negatively affect the resident's health.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure proper storage, labeling, and disposal of medications. * The facility failed to ensure the medications for Residents 22 and 53 who were discharged to home, Resident 2 who was transferred out of the facility, and Resident 63 who had expired was removed from the current medication supply in Medication Room A and Medication Cart A. * The facility failed to ensure the expired medications had been removed from the current medication supply in Medication Cart B. * The facility failed to ensure the opened foil pouches of inhalation solution medications for Residents 5, 15, and 40 in Medication Cart A were labeled with an opened date. [...]

Inspectors wroteBased on interview, facility document review, and facility P&P review, the facility failed to ensure the infection control practices designed to provide the safe and sanitary environment and help prevent the development and transmission of infections were implemented as evidenced by: * The facility failed to ensure the water management program was implemented to include an assessment of the facility water systems to identify where Legionella (a bacterium commonly found in natural and man-made aquatic environments, warm stagnant water) and other opportunistic pathogens can grow and spread. * The facility failed to ensure the infection control practices were implemented in the facility's laundry room. These failures posed the risk for transmission of communicable diseases to other residents in the facility.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the essential equipment was maintained in safe operating condition. * The facility failed to ensure the staff performed calibration before using a new glucometer (a device which measures the amount of sugar in the blood). This failure had the potential for residents requiring glucose checks to have inaccurate readings. * The facility failed to ensure the freezer compartment inside the refrigerator used for medications in Medication Room A was free of ice buildup. This failure had the potential to affect the refrigerator's functionality and the potential to affect the potency of the medications stored inside the refrigerator.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to document the resident's name on a facility document for one of 16 final sampled residents (Resident 366). This failure posed the risk for Resident 366 to not receive accurate and necessary care.

Inspectors wroteBased on interview, medicalrecord review, and facility P&P review, the facility failed to ensure the controlled substance medications (medications with high risk for abuse andaddiction) were appropriately accounted for one of two sampled residents (Resident 1). This failure had the potential to negatively affect the health and safety of the resident.

Inspectors wroteBased on interview and medical record review, the facility failed to send a copy of the transfer/discharge notice to the Long-Term Care Ombudsman for one of three closed record sampled residents (Resident 54). This posed the risk of the Ombudsman not being aware of the circumstances should an appeal be filed by the resident or their representative regarding the transfer/discharge.

Inspectors wrote2. Review of the facility's P&P titled Change of Condition dated 3/2021 showed it is the policy of this facility that any significant changes in a resident's condition be thoroughly assessed and evaluated with physician notification for early clinical management to avoid unnecessary readmissions to acute hospitals. The facility may use the SBAR process to access and evaluate the resident's change of condition. Medical record review for Resident 24 was initiated on 8/2/21. Resident 24 was was initially admitted to the facility on [DATE], and readmitted on [DATE]. On 8/2/21 at 0800 hours, Resident 24 was observed with a dried blood clot on the left side of his lips and had a small amount of blood dripping down his left cheek. On 8/2/21 at 0851 hours, the left side of Resident 24's lips was observed bleeding with a small amount of blood dripping down his left cheek. [...]

Inspectors wrote2. Medical record review for Resident 31 was initiated on 8/4/21. Resident 31 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the MDS dated [DATE], showed Resident 31 was cognitively intact and totally dependent on two or more staff members for bed mobility. Review of the Braden Scale for Predicting Pressure Sore Risk dated 7/6/21, showed Resident 31 was at moderate risk for developing pressure ulcers. On 8/4/21 at 1044 hours, a wound treatment observation for Resident 31 was conducted with LVN 2 and CNA 1. Resident 31's left flank, from the left scapula to the left lower rib cage, was observed with a large area of opened skin, measuring 23 cm (length) x 15 cm (width). The flank area was red and had sanguineous drainage, and some areas had bleeding. The whole wound was observed covered in a white substance. [...]

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the necessary care and services to ensure adequate assistance was in place for one of 14 final sampled residents (Resident 15). This posed the potential for Resident 15 to sustain a fall or injuries.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the necessary care and services to attain and maintain the highest physical well-being for one of 14 final sampled residents (Resident 152) who required dialysis. * The facility failed to ensure the physician's order for a 1000 ml fluid restriction (a diet which limits the amount of daily fluid consumption) was followed and carried out accordingly. This had the potential to result in Resident 152 having excess fluids which may affect other vital organs in the body due to impaired kidney function.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 14 final sampled residents (Resident 103) and one nonsampled resident (Resident 21) were assessed for entrapment associated with the use of elevated grab bars and informed consent was obtained for the use of the grab bars. * The facility failed to ensure the assessments for the risk for entrapment were completed for Residents 21 prior to the use of grab bars. In addition, the facility failed to develop a plan of care addressing the use of grab bars. * The facility failed to ensure Resident 103 was assessed for the risk of entrapment nor an informed consent was obtained for the use of the grab bars. These failures had the potential to put the residents at risk for entrapment and serious injury.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure proper accounting and safeguarding of the controlled medications in order to prevent loss, diversion, or accidental exposure. * The facility failed to ensure the incoming and outgoing licensed nurses assigned to Medication Cart B consistently signed the Narcotic Count Sheet log. This failure created the risk of drug diversion in the facility.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the Pharmacy Consultant's recommendations were acted upon for one of 14 final sampled residents (Resident 15). The Pharmacy Consultant recommended for a lipid panel test (complete cholesterol test, a blood test that can measure the amount of cholesterol and triglycerides in the blood) for the use of simvastatin (medication used to treat high cholesterol and triglyceride levels) was not acted upon. The facility's failure to act upon the Pharmacy Consultant's recommendations had the potential to put Resident 15 at risk for adverse consequences related to the medication.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure one of 14 final sampled residents (Resident 15) was free from unnecessary psychotropic drugs (any drug that affects brain activity). * The facility failed to ensure the side effects were monitored for the administration of valproic acid (anticonvulsant, medication used to treat seizures and bipolar disorder). This had the potential for Resident 15 to have adverse complications from the medication.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 28.57%. * LVN 3 failed to administer Resident 9's medications in a timely manner. This failure posed the risk of complications and ineffective therapeutic effects of the medications.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to implement their infection control P&P designed to prevent the spread of infection in the facility. * The facility failed to ensure LVN 6 wore a faceshield in the resident care areas. In addition, the facility failed to ensure the faceshield was stored or discarded properly. * Multiple medication bottles in Medication Cart A had stains and sticky residues. The medication drawer holding the liquid medications in Medication Cart A had sticky residues. These failures had the potential for the spread of infection in the facility.

Inspectors wroteBased on observation and interview, the facility failed to maintain an effective pest control program. * The fire exit door at Nurses' Station B was observed to be left ajar. In addition, a gap was observed at the bottom portion of the fire exit door and floor threshold. An open cracked area on the left lower corner of the fire exit door was observed. These failures posed the risk for vermin entering the facility and potential safety hazard for the residents, staff, and visitors.

Inspectors wroteBased on observation and interview, the facility failed to ensure seven out of eight residents interviewed (Residents 2, 4, 7, 18, 22, 50, and 357) were informed of their rights to formally complain to the State agency (CDPH, L&C Program) about the care they received. This posed the risk of residents not knowing how to contact the State agency should the residents require the State agency's services.