La Paz Geropsychiatric Center

Inspectors wroteBased on interview and record review the facility failed to notify the physician of an elevated laboratory result for one of five sampled residents (Resident 5's). The facility failed to:1. Ensure Resident 5's physician was notified of elevated prostate-specific antigen level (PSA- a simple blood test to help look for [prostate- a walnut-sized gland in the male reproductive system that makes fluid for semen] problems) laboratory result of 18.2 nanograms (ng-unit of measurement)/milliliters (mL- unit of measurement) greater than 10 ng/mL: Probability of prostate cancer - 50%) dated 1/28/2026.2. Document physician notification or obtain timely follow-up after the abnormal laboratory result was identified. This deficient practice had the potential to delay physician evaluation, diagnostic workup, and implementation of appropriate medical treatment for Resident 5.

Inspectors wroteBased on interview, and record review, the facility failed to protect one of four sampled residents (Resident 1) from potential and/or continued sexual abuse when Resident 1 reported to the facility's Social Worker (SW) on 5/19/2026 at 4:35 p.m., that Resident 2 touched her (Resident 1) buttock four times with his hand. Resident 1 and 2 were not placed on every 15 minute monitoring, per their intervention, until 5/20/2026 at 1:30 p.m. (approximately 21 hours after the allegation was made). This deficient practice resulted in Resident 2 being unmonitored for 21 hours after Resident 1 alleged sexual abuse against Resident 2. This deficient practice placed Resident 1 at risk for continued sexual abuse by Resident 2.

Inspectors wroteBased on interview, and record review, the facility failed to report an allegation of sexual abuse for one of four sampled residents (Resident 1) when Resident 1 reported to Social Worker ( SW ) 2 that Resident 2 touched her buttocks. This deficient practice resulted in the California Department of Public Health (CDPH) being unaware of the allegation of sexual abuse and had the potential to affect the CDPH's ability to conduct a timely investigation.

Inspectors wroteBased on interview and record review, the facility failed to ensure an informed consent (a document ensuring the resident was educated of the risks and benefits of the treatment and agreed or disagreed to continue with the treatment) was obtained for one of one resident's (Resident 3) Zyprexa (olanzapine - a medication used to treat mental health conditions such as schizophrenia [a mental illness that is characterized by disturbances in thought] and bipolar disorder [sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs]) prior to administration on 5/18/2026. This deficient practice resulted in Resident 3 receiving Zyprexa without being informed of the medications purpose, risks, benefits, and potential side effects.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one resident's (Resident 3) administration of Zyprexa (olanzapine - a medication used to treat mental health conditions such as schizophrenia [a mental illness that is characterized by disturbances in thought] and bipolar disorder [sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs]) and Benadryl (diphenhydramine - a medicine given to treat or prevent side effects caused by antipsychotics medications) was documented upon administration on 5/5/2026. This failure had the potential to result in inaccurate medication records, uncertainty regarding whether Resident 3 received Zyprexa and Benadryl as ordered by the physician, unmonitored medication effectiveness and adverse effects, and medication errors.

Inspectors wroteBased on interview and record review, the facility failed to protect the residents right to be free from physical abuse for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure Licensed Vocational Nurse (LVN)1 redirected Resident 1 and Resident 2 away from each other after she observed Resident 1 placing her hand on Resident 2's back. 2. Ensure facility staff provided immediate 1:1 supervision for Resident 1 after an altercation with Resident 2. These failures resulted in Resident 2 being assaulted by Resident 1 on 4/22/2026 and a second allegation of physical abuse on 4/22/2026, when Resident 3 alleged Resident 1 punched her in the face and nose. These failures had the potential to place other residents who resided in the facility at risk for abuse.

Inspectors wroteBased on interview, and record review, the Facility failed to:develop and update a person-centered care plan for two of six sampled residents (Resident 1 and 6) by failing to:a. Develop or update the care plan upon readmission on [DATE] when Resident 1 exhibited aggressive behaviors.b. Develop a specific care plan addressing Resident 6's aggressive behaviors, including defined interventions for monitoring the aggressive behavior. This deficient practice had the potential to result in inadequate behavioral monitoring, interventions and compromise resident's safety.

Inspectors wroteBased on observation and record review the facility failed to accurately and completely maintain the 24-hour observation checklist (every 15 minutes safety monitoring observation checklist) for four of five sampled residents as evidenced by the following: a. CNA 1 documented Resident 3, 5, and 7's 10:00 and 10:15 a.m. observations in advance of the scheduled times on 2/18/2026.b. CNA 1 documented Resident 4's 9:45 a.m. 10:00 a.m. observation without having observed the patient on 2/18/2026. This deficient practice resulted in inaccurate documentation and had the potential to compromise resident safety and the reliability of required monitoring and observation.

Inspectors wroteBased on observation, interview and record review, the facility failed to protect the residents' right to be free from physical abuse for two of four sampled residents (Resident 3 and Resident 1). The facility failed to:1. Ensure Resident 4 did not push down Resident 3 who was trying to get up from the couch, held Resident 3's arm down and Resident 3 did not hold onto Resident 4's arm and kicked in an attempt to get up on 12/29/2025 at 5:30 p.m. during group activity in the living room.2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident did not sustain unplanned severe weight loss (a weight loss greater than 5 % in one month, greater that 7.5% in three months and greater than 10 % in 6 months) of 37 pounds ([lbs. unit of measurement] 24 percent [%] in five months for one of three sampled residents (Resident 8). The facility failed to: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper food handling practices were followed. The facility failed to ensure that a dietary aide washed her hands and wore a hairnet before entering the food preparation area after coming from outside. This deficient practice had the potential to result in food contamination and increase the risk of foodborne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) among residents.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure three of seven sampled residents (Resident 41, Resident 55 and Resident 134) were treated with respect and dignity. The facility failed to 1. Provide a privacy curtain in Resident 55's room. 2. Close Resident 40 and 134 privacy curtains to protect residents' privacy during medication administration. These failures had the potential to result in feelings of decreased self-esteem and self-worth for Resident 41, Resident 55 and Resident 134.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure four of six sampled residents' psychotropic medication (a drug that changes brain function and results in alterations in perception, mood, consciousness or behavior) informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered), prior to starting medication. The facility failed to:1. Provide Resident 2, Resident 8, and Resident138 were provided with psychotropic medication informed consent, prior to starting medication. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Notice of Proposed Transfer and Discharge was provided to the Ombudsman (resident advocate) at the time of discharge for three of three sampled residents (Resident 2, Resident 6 and Resident 154). This deficient practice had the potential to deny Resident 2, Resident 6 and Resident 154 protection from being inappropriately discharged and violated the residents' rights.

Inspectors wroteBased on interview and record review, the facility failed to:1. Include signatures of two Licensed Vocational Nurses (LVNs) on the medication donation records titled Medication Destruction Record for 35 records on three out of three sampled pages in the donation log, as per facility's policy and procedure (P&P) titled, Donated Medications, dated 10/10/2024.2. Ensure the disposition or destruction records for controlled medications (medications that the use and possession of are controlled by the federal government) included signatures of a pharmacist in addition to a Registered Nurse (RN) or Director of Nursing (DON) on six of six sampled records, as per facility's P&P titled Accounting for Administered and Wasted Medications including Expired Medications, dated 6/11/2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and observe infection control practices by failing to:1. Ensure the laundry staff performed hand hygiene prior to handling clean linens.2. Ensure the laundry staff were keeping a log and monitoring the washing machine water temperatures and ensure the water heater was functioning prior to using the washing machines. 3. Perform proper hand hygiene procedures after checking Resident 140's blood glucose, and before and after administering insulin (medication that lowers blood sugar level), per facility's policy and procedure (P&P) titled, Hand Hygiene, dated 12/9/2024, affecting one of nine residents observed during medication administration.4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the physician for a change in condition for one of three sampled residents (Resident 117), when Resident 117 verbalized suicidal ideations. This deficient practice had the potential for delayed physician assessment and intervention, placing Resident 117 at risk for delayed behavioral health intervention, worsening psychiatric symptoms, and possible harm. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a comfortable, homelike, and safe environment for one of six sampled residents (Resident 124). The facility failed to:1. Ensure adequate water flow during Resident 124's shower time.2. Maintain the physical environment by allowing the baseboard in a shared resident bathroom to peel off. This deficient practice had the potential to negatively impact Resident 124's well-being and posed a risk of accidents or injury to residents due to an unsafe and poorly maintained environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of three sampled residents (Residents 63) were free from sexual abuse by another resident (Resident 146). The facility failed to: 1. Supervise Resident 146 with history of inappropriate sexual comments towards staff and residents, showing his private part, standing too close to staff and not giving enough boundaries. This failure had the potential to result in Resident 63 experiencing unwanted sexual contact, placing the resident at risk for emotional trauma, psychological harm, and a compromised sense of safety within the facility.

Inspectors wroteBased on observation and record review the facility failed to ensure monitoring was done for psychotropic medications (medication used to treat mental health disorders) for two of six sampled residents (Resident 2 and Resident 8) when:1. Resident 2's target behaviors were not monitored.2. Resident 8's side effects were not monitored. These failures had the potential to cause harm to Resident 2 and Resident 8's quality of life and possible unwarranted use of psychotropic medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop an individualized care plan with measurable objectives, time frame, and interventions to meet the residents' needs for two of three sampled residents (Resident 112 and Resident 117) by failing to:1. Develop an individualized care plan with goals and interventions for Resident 112's hip pain and refusal of care.2. Develop an individualized care plan with goals and interventions for Resident 117's suicidal ideation. These deficient practices had the potential to negatively affect the delivery of necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide one of 18 sampled residents (Resident 88) with meaningful activities or regular room visits as part of an ongoing program designed to support the resident's individual choices and preferences for activities. This deficient practice had the potential to negatively impact the resident's sense of self-worth and psychosocial well-being, contributing to feelings of isolation, decreased self-respect, and diminished self-satisfaction.

Inspectors wroteBased on interview and record review, the facility failed to assess and provide treatment for constipation for one of three sampled residents (Resident 96), when Resident 96 did not have a bowel movement for four consecutive days on two separate occasions. This deficient practice resulted in delayed intervention and had the potential to cause abdominal discomfort, distention, and bowel obstruction. During a review of Resident 96's admission Record, the admission Record indicated the facility admitted Resident 96 on 6/27/2019, with diagnoses including major depressive disorder (a mood disorder that causes a persistent feelings of sadness and loss of interest), schizoaffective disorder (mental illness that can affect thoughts, mood, and behavior), and movement disorder (a neurological condition causing problems with movement either with too much, too little, or slow movement). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents with or without limited range of motion (ROM-movement of joints) received appropriate treatment and services to maintain or improve mobility to ensure that one of four sampled residents (Resident 88), who had physician's orders for ROM exercises, received services as directed by the Restorative Nursing Assistant (RNA). This deficient practice had the potential to contribute to the development of contracture (conditions involving the shortening and hardening of muscles, tendons, or other tissues) and decreased functional ability in Resident 88's extremities.

Inspectors wroteBased on observation and interview, the facility failed to ensure the privacy curtain was secured to its curtain rack for one of one resident (Resident 138). This failure had the potential for Resident 138 to sustain an injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of two sampled residents (Resident 56) received effective pain management. The facility failed to:1. Ensure that Licensed Vocational Nurses (LVNs) administered appropriate pain medication based on Resident 56's assessed pain level. This deficient practice had the potential to result in inadequate and ineffective pain management for Resident 56, placing the resident at risk for unnecessary discomfort, and potential decline in physical and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure Licensed Vocational Nurse (LVN 4) received in-service training on physician notification, weight loss, nutrition, and hydration. This failure had the potential to result in residents not receiving appropriate nursing care and posed a risk of harm due to unmet healthcare needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure actual hours worked was posted in an area visible to residents and the public. This failure had the potential to mislead residents and families about nursing staff and potentially affecting residents' care and safety. During an observation on 10/22/2025 at 10:28 a.m. the nurse staffing document titled Daily Schedule was posted by the entrance in between the staff restroom and living room near the nursing station. The Daily Schedule was updated with staff call offs and add on but did not indicate actual hours worked. During an observation on 10/23/2025 at 7:40 a.m. the nurse staffing titled Daily Schedule was posted by the entrance in between the staff restroom and living room near the nursing station. The Daily Schedule was updated with staff call offs and add on but did not indicate actual hours worked. [...]

Inspectors wroteBased on interview and record review, the facility's Quality Assurance and Performance Improvement (QAPI data-driven plan of action to correct identified and potential problems) failed to maintain and develop action to correct identified and potential problems. The facility failed to:1. Provide effective oversight and ensure implementation of the plan of correction related to the deficient practice identified during the previous recertification survey regarding the prevention, identification, and reporting of abuse.2. Identify and monitor residents at risk for weight loss to ensure timely interventions and prevent further decline. These failures had the potential to negatively impact residents' quality of care and safety, and could result in abuse going unrecognized and uninvestigated, as well as unaddressed nutritional decline among vulnerable residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure Social Worker (SW) 2 received effective training on abuse reporting, related to identifying and reporting inappropriate sexual behavior of Resident 146 towards Resident 136 and 155. This deficient practice had the potential to result in incidents of abuse going unrecognized and unreported, placing residents at risk for harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that resident bedrooms did not accommodate more than four residents, as required. The facility failed to ensure:1. Rooms 12, 13, 20, and 21 did not exceed the maximum occupancy by having six residents each and rooms [ROOM NUMBER] did not exceed the limit by having five residents each. This failure had the potential to compromise residents' privacy, reduce their quality of care, and negatively impact their overall quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident ' s (Resident 1) privacy when Resident 2 walked into the restroom while Resident 1 had her pants down while urinating. This failure resulted in Resident 1 feeling embarrassed, bad, and nasty.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one out of four sampled residents (Resident 1) was free from physical abuse (any intentional act causing injury or trauma to another person or animal by way of bodily contact) by Resident 2. As a result, Resident 2 entered Resident 1 ' s bathroom as Resident 1 was sitting on the toilet with her pants down around her ankles and Resident 2 punched Resident 1 on the right cheek, leaving a red mark on Resident 1 ' s right cheek. Resident 1 felt stated she felt mad, nasty, and embarrassed a man (Resident 2) was in her (Resident 1 ' s) female bathroom while her pants were down during the physical altercation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide supervision for one of one male resident (Resident 2) with history of wandering from entering an occupied female ' s restroom (Resident 1). This failure resulted in Resident 1 being exposed with her pants down and punched in the right cheek.

Inspectors wroteBased on interview and record review, the facility staff members failed to notify the physician when Tamiflu (medication used to prevent and treat infections caused by the flu virus) was not available immediately when residents were symptomatic for two of seven sampled residents (Resident 5 and 4). This deficient practice had the potential to delay medical interventions.

Inspectors wroteBased on interview and record review, the facility failed to implement their careplan for four of seven residents (Resident 5, 4, and 3) and did not monitor the vital signs every four hours as indicated. This deficient practice had the potential to compromise other resident's wellbeing.

Inspectors wroteBased on interview, and record review, the facility failed to ensure Tamiflu (Oseltamivir Phosphate: prevents and treats infections caused by the flu virus) medications was administered to meet the needs for two of seven sampled residents (Resident 5 and Resident 4). This deficient practice had the potential to result in a delay in administration of necessary medication for the residents.

Inspectors wroteBased on interview and record review, the facility failed to enforce its own policy related to Influenza (contagious respiratory illness caused by the influenza virus) outbreak by not retesting contaminated samples collected on 12/27/2024 and reordering test kits on a timely manner for two out of 12 residents (Resident 5 and Resident 4) that were symptomatic. These deficient practices had placed all residents, staff, vendors, visitors, and the surrounding community at risk for spread of the influenza virus.

Inspectors wroteBased on interview and record review, the facility failed to ensure 9 out of 62 residents (Resident 3, Resident 7, Resident 14, Resident 15, Resident 16, Resident 21, Resident 81, Resident 107, and Resident 128) who were a smokers continue to smoke in an area that maintains the quality of life for these residents. The facility failed to: 1. Follow facility's policy and procedure (P&P) titled Smoking Policy for Skilled Nursing Facilities approved on 1/31/2024, which indicated Smoking is recognized as a privilege and the facility will adhere to all city, state, and federal regulations. If the facility changes its policy to prohibit smoking, the facility will allow current residents who smoked to continue smoking in an area that maintains the quality of life for these residents. [...]

Inspectors wroteBased on observation interview and record review the facility failed to: a. Ensure expired bagels were removed from shelfs. b. Ensure the floor in the kitchen all along the walls and in the corners was free from food crumbs and dirt build up. c. Ensure the drain face plate used for multiple kitchen equipment (ice machine, freezer, and coffee machine) was clean and free from blackish greenish slimy substance. These failures had the potential to expose residents to food-borne illnesses (any illness resulting from ingestion of food contaminated with bacteria, viruses, or parasites) and put residents at risk for cross contamination (unintentional transfer of harmful bacteria from one object to another).

Inspectors wroteBased on interview and record review, the facility's Quality Assurance Performance Improvement (QAPI, a data driven proactive approach to improvement used to ensure services are meeting quality standards) failed to maintain and develop an effective plan of action to correct an identified and potential problems by failing: 1. To provide an effective oversight of the facility and implementation of the facility's plan of correction (POC) of the deficient practice regarding abuse reporting and call lights accessibility for residents from the previous recertification survey. 2. To identify and address problems with the implementation of no smoking among the residents who are smokers. [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to ensure call light was within reach for three of three sampled residents (Resident 132, 140 and Resident 141). This deficient practice had the potential for Resident 132, 140 and 141 not to receive necessary assistance when needed, and experienced loss of self-esteem.

Inspectors wroteBased on observation, interview and record review, the facility failed to notify resident physician for two of six sampled residents (Resident 14 and Resident 108) who were manifesting tremors (involuntary , rhythmic shaking and trembling of one or more parts of the body) on their hands and arms that affected their activities of daily (ADL- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). This failure had the potential to affect Resident 14 and Resident 108 daily functioning and quality of life. This failure had the potential for Resident 14 and 108 to feel frustrated and helpless.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of four sampled residents (Resident 65 and Resident 89) was free from physical abuse by failing to: 1. To protect Resident 65 from Resident 37 who hit a staff member on the way to their room, and then hit Resident 65 with a table who was her roommate. This failure resulted Resident 65 getting hit by the table sustaining a small cut to right forehead.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide individualized activities that meets the interest of the resident's for three of three sampled residents, (Resident 3, 21 and 104). This failure had the potential to impact the mental and psychosocial wellbeing of Resident 3, 21 and 104, exacerbating feelings of depression that could impact residents' quality of life.

Inspectors wroteBased on interview and record the facility failed to ensure 3 out of 3 Certified Nursing Assists (CNA) had completed their facility assigned mandatory on-line continuing education requirements with facility on-line continuing education program. Facility failed to: 1. Ensure Certified Nursing Assistant (CNA) 1, CNA 2 and CNA 3 had yearly mandatory dementia (loss of memory, language, problem-solving and other thinking abilities) training 2. Ensure CNA 2 and CNA 3 had completed one hour of mandatory yearly sexual harassment training. This failure had the potential to put the resident's safety at risk when training requirements were not completed.

Inspectors wroteBased on interview and record review the facility failed to ensure one of 33 sampled residents (Resident 139) had a comprehensive care plan developed and implemented for diagnosis of schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). This failure had the potential to result in a delay of the delivery of care and services.

Inspectors wroteBased on interview, and record review, the facility failed to ensure a care plan for vision was revised and updated for one of 33 sampled residents (Resident 108). This failure had the potential to put Resident 108 at risk for not receiving the care and services needed to meet her individualized needs.

Inspectors wroteBased on interview and record review the facility failed to ensure the Director of Staff Development (DSD- plans, directs, or coordinates the training for staff) was competent in obtaining report of facility staff's annual mandatory training with the use online education program. This failure had the potential for the facility not be able to assess the skills necessary to provide nursing services to assure resident safety.

Inspectors wroteBased on interview and record review, the facility failed to implement their protocol for Antibiotic Stewardship (refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use) for one of 33 sampled residents (Resident 139) by obtaining culture ( a laboratory test that analyzes a sample of body fluid or tissue to identify harmful bacteria, fungus, or viruses that may be causing an infection ) or blood tests prior to prescribing antibiotic medication (a substance used to kill bacteria and to treat infections) after being screened for cellulitis (bacterial skin infection that may appear as a red, swollen area, feeling hot and tender to the touch). This failure had the potential for Resident 139 to develop antibiotic resistance (not effective to treat infection) from inappropriate antibiotic use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate no more than four residents by failing to ensure rooms 12,13,20 and 21 did not accommodate six residents, and room [ROOM NUMBER],47 and 48 did not accommodate five residents. This failure had the potential to decrease the resident's privacy, quality of care and quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to protect the resident rights to be free from physical abuse for one of two sampled residents (Resident 1) by a resident. This failure resulted in Resident 2 stabbed Resident 1 on his right index finger repeatedly with a pen. Resident 1 sustained a one inch cut on the right index finger.

Inspectors wroteBased on observation, interview, and record review the facility failed to protect the residents' right to be free from physical abuse by another resident for two of four sampled residents (Resident 2 and 4). The facility failed to: a. Ensure Resident 1's physician was informed when he was exhibiting behaviors such as auditory hallucination ([AH] hear voices or noises that are not there), paranoid delusion ([PD] a type of serious mental illness where patient cannot tell what is real from what is imagined.), and visual hallucination([VH] perception of an external visual stimulus where none exists). b. Ensure Resident 3's physician was informed when he was exhibiting behaviors such as agitation ([AG] manifested by striking out), anxiety ([AX] persistent and excessive worry) and mood swings ([MS] extreme of sudden change of mood). [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure the resident, who had a history of physical aggressive behavior towards staff and resident did not physically abuse another resident and facility staff for one of two residents sampled residents (Resident 1). The facility failed to: 1. Ensure Resident 1 was assessed and supervised for aggressive behavior towards staff and residents to prevent the resident from physically attacking Resident 1 and Registered Nurse Supervisor (RNS) 1 on 2/17/2024. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement infection control practices to prevent the development and transmission of communicable diseases and infections. The facility failed to: 1. Monitor and document the vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions) for five of five sampled residents (Resident 4, 5, 6,7, and 8) who were tested positive of COVID-19 infection (a highly contagious infection, caused by a virus that can easily spread from person to person). 2. Ensure three of five sampled residents (Resident 4,7, and 8) received Paxlovid (a medication to treat Covid 19 infection) within five days of symptom onset and documenting a reason for contraindication if it was not given. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to assess the residents for eligibility and failed to ensure residents were offered the pneumonia (an infection of the lungs) vaccination (medication to prevent a particular disease) and influenza (contagious respiratory disease that can cause mild to severe illness) vaccination for one of five sampled residents (Resident 5). This failure had the potential to result in Resident 5 being at a higher risk of acquiring and transmitting pneumonia and influenza to other vulnerable and immunocompromised residents in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to: a. Ensure open plastic package of liquid eggs waswith open dates and expiration dates. b. Ensure employees' rotisserie chickens were not stored in the residents' refrigerator. c. Ensure the cook performed hand washing after removal of gloves during lunch food plating and preparation. These failure had the potential to place residents at risk for food borne illness (any illness resulting from ingestion of food contaminated with bacteria, viruses, or parasites).

Inspectors wroteC.During a concurrent observation and interview on 10/19/2023, at 4:08 p.m. with Housekeeping and Laundry Supervisor (HLS), dryer number 1 and 2 had digital readings of 180 degrees Fahrenheit ([F] unit of measurement) but dryer number 3 had no temperature reading visible on the dryer machine. HLS stated the facility did not have a log of dryers' temperature. During an interview on 10/19/2023, at 4:22 p.m. with Facilities Manager (FM), FM stated the facility did not track or maintain a log of temperatures for the dryers. FM stated the laundry staff members would touch the glass lid of the dryers to ensure the dryer was drying the clothes properly. FM stated if the glass lids are cold, it would mean the dryers are not drying the residents' clothes completely and he would be called to check or troubleshoot the dryer machines. During an interview on 10/19/2023, at 4:26 p.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure four of eight sampled residents (Residents 43, 73, 98, and 115) received treatment and services to prevent a decline in range of motion (ROM, full movement potential of a joint) and mobility by failing to: 1. Ensure Resident 43's Restorative Nursing Aide (RNA, nursing aide program that helps residents maintain their function and joint mobility) order dated 6/15/2023 included the distance to walk to maintain the distance of 400 feet of ambulation (walking ability) after discharge from Physical therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) on 1/3/2023 2. Ensure the RNA order included the specific type of exercises for RNA to perform during RNA treatment to maintain mobility and ROM for Resident 73. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to address significant (resident loses five percent [%] of total weight in one month, or 7.5% in three months, or 10% in 6 months) weight loss for two of 31 sampled residents with weight loss (Resident 5 and Resident 120). The facility failed to: 1. Ensure the cause of Resident 5's decreased food intake and 25 lbs weight loss in six months was evaluated and interventions implemented to prevent the resident's further weight loss by assessing the resident's food likes and dislikes, honoring Resident 5's food preferences, and/or offering alternative food items. 2. Ensure nursing staff evaluated, monitored, and had interventions in place to prevent Resident 120's weight loss of 23 pounds (lbs), in 6 months. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light device was within reach for one of eight sampled residents (Resident 68). This failure had the potential to prevent Resident 68 from receiving necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of suspected resident to resident altercation in a timely manner for one of three residents (Resident 105) after the allegation was reported to the Administrator (ADM)by the California Department of Public Health (DPH works to protect the public's health in California) on 10/17/2023. This failure had the potential to result in psychosocial and emotional harm on Resident 105.

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement a resident-centered care plan with measurable objectives, timeframes, and interventions for one of five sampled residents (Resident 22) who was admitted to the facility with pressure ulcer (injuries to skin and underlying tissue resulting from prolonged pressure on the skin). This deficient practice had the potential to negatively affect the delivery of necessary care and services for Resident 22.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of eight sampled residents (Resident 68) received the services to maintain or improve the ability to perform activities of daily living (ADLs, basic activities such as eating, dressing, toileting) This deficient practice had the potential to place Resident 68 at high risk for further ADL decline, generalized deconditioning (decline in physical function of the body because of physical inactivity), decreased joint mobility (movement around a joint), and decreased quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to ensure resident that has visual impairment was assisted to get new eyeglasses for one of 5 sampled residents, (Resident 73). This deficient practice has a potential for Resident 73 to have a decrease in preferred activities of daily living (ADLS [ability to care for yourself without assistance]) and had the potential for injury, falls and decrease in overall quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Assessed and provide intervention when Resident 65's persistent complained of pain to right and left hip and does not want to get out of bed and attend social activities outside her room. 2. Informed Resident 65's physician of her complained of right and left hip pain with pain level of 10/10 (a numerical tool to measure the severity of pain, with 0- as no pain and 10 represents the most severe or worst pain you have ever experienced). 3. Implement Resident 65's care plan (CP) goal to be free from pain and interventions including observe and report pain to the physician and will be able to maintain her activities of daily living. [...]

Inspectors wroteBased on interview and record review, the facility failed to: 1.to follow physician order for administering pain medication for moderate pain (pain level of 4-7)for one of five sampled resident (Resident 70). 2.to administer Naprosyn( used to relieve pain and reduces inflammation) every twelve hours for a pain level of zero (indicating no pain). These deficient practices had the potential to place Resident 70 at risk for a heart attack, stomach ulcers (bleeding in your stomach) and stroke (when blood flow to the brain is blocked or there is sudden bleeding in the brain) that could lead to death.

Inspectors wroteBased on observation, interview, and record review the facility failed to monitor the side effects (undesirable effect of medication ) of Depakote (medication used to treat conditions that affect the brain) and properly monitor the extrapyramidal symptoms (EPS-movement disorders that can occur as a side effect of antipsychotic medications (class of drugs used to treat various mental health conditions) of olanzapine (antipsychotic medication) , benztropine (medication used to treat tremors or stiffness), and amantadine (medication used to treat tremors, shaking ) for one of 31 sampled Residents (Resident 85) This deficient practice resulted in the misidentification of side effects and extrapyramidal symptoms of Resident 85.

Inspectors wroteBased on interview and record review the facility failed to obtain laboratory testing per physician order and report an abnormal laboratory result to Resident 85's physician. This deficient practice had the potential for Resident 85 to receive inadequate medications and delayed treatment.

Inspectors wroteBased on observation, interview and record review the facility failed to follow up necessary dental services for one of two sampled residents (Resident 43). This deficient practice had the potential to cause a delay in treatment and place Resident 43 at risk for infection.

Inspectors wroteBased on interview and record review, the facility failed to offer and administer pneumococcal vaccine (vaccine which helps prevent infection by Streptococcus [bacterium that causes one of the most common and severe forms of pneumonia (infection of the lungs)]) upon admission and with 30 days of admission to the facility for one of five sampled residents (Resident 126). This deficient practice had the potential on increased risk for Resident 126 of acquiring and transmitting pneumonia to other resident and staff in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate no more than four residents by failing to ensure rooms 12,13,20 and 21 did not accommodate six residents, and room [ROOM NUMBER] and 47 did not accommodate five residents. This deficient practice had the potential to decrease the resident's privacy, quality of care and quality of life.