Las Flores Convalescent Hospital

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident call lights were placed within reach, for three of four sampled residents (Residents 1, 2 and 3). This failure resulted in the residents being unable to reach the call lights and had the potential that residents could not call nurses for help when immediate assistance is needed. This failure had to potential to negatively impact the residents' psychosocial well-being and delay in proving the needed care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive, person-centered care plan for one of four sampled residents' (Resident 4) refusal of nicotine patch (transdermal patches that deliver a steady dose of nicotine through the skin to help reduce cravings and withdrawal symptoms such as restlessness, low mood, irritability, and poor concentration). This deficient practice resulted in no further interventions provided and had the potential to delay the resident's goal to quit smoking.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 4), received the nicotine transdermal patch (which delivers nicotine through the skin to help reduce smoking cravings) as ordered and notify the physician when the resident refused the medications. These failures placed the resident at risk for withdrawal symptoms such as restlessness, low mood, irritability, and poor concentration, which can affect the Resident 4's ability to maintain their highest practicable physical, mental and psychosocial well-being.

Inspectors wroteBased on observation and interview, the facility failed to ensure expired and unlabeled food items were not in the kitchen. This deficient practice had the potential to cause foodborne illnesses for residents.

Inspectors wroteBased on observation and interview, the facility failed to provide dignity and respect for one of four sampled residents (Resident 67) when his indwelling urinary catheter (a flexible tube inserted into the bladder to continuously drain urine) collection bag was not covered with a privacy cover. This deficient practice resulted in Resident 67 feeling embarrassed that people could see his urine.

Inspectors wroteBased on interview and record review, the facility failed to obtain and document informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for one of five residents (Resident 9) prior to administering treatment with psychoactive medications (a drug that changes brain function and results in alterations in perception, mood, consciousness or behavior.)This deficient practice violated Resident 9 and Resident 9's Responsible Party (RP)'s right to make an informed decision regarding the use of psychoactive medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure an interdisciplinary team ([IDT] team members from different disciplines who come together to discuss resident care) meeting was conducted after a Significant Change in Status Assessment ([SCSA]) - a comprehensive assessment that must be completed when the IDT has determined that a resident meets the significant change guidelines for either improvement or decline) for one of one sampled resident (Resident 10). This deficient practice violated Resident 10's and his representative's rights to be fully informed and had the potential to result in a delay of care and services.

Inspectors wroteBased on interview and record review, the facility failed to accommodate the needs and preferences of one out of three sampled residents (Resident 22) by failing to honor and carry out a physician-ordered therapeutic Out-on-Pass. This deficient practice resulted in Resident 22 not being able to go out on pass when preferred.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set ([MDS] - a federally mandated resident assessment tool) for Significant Change in Status Assessment ([SCSA]) - is a comprehensive assessment that must be completed when the Interdisciplinary Team ([IDT] - team members from different disciplines who come together to discuss resident care) has determined that a resident meets the significant change guidelines for either improvement or decline) was completed for one of one sampled resident (Resident 10). This deficient practice had the potential to result in inaccurate care and services for Resident 10 due to inappropriate MDS care screening and assessment tool practices.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 52) had care plans (a personalized document outlining a resident's health needs, goals, and specific interventions) for diagnosis Type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication.)This deficient practice had the potential to result in delayed care and services for Resident 52.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure oxygen was administered as ordered for one out of one sampled resident (Resident 62). This deficient practice had the potential to lead to oxygen toxicity.

Inspectors wroteBased on interview and record review, the facility failed to provide medically related social services (services provided by the facility's staff to assist residents in attaining or maintaining their mental and psychosocial health) such as an outside referral for anger management support group therapy (a structured, supportive environment where people learn to recognize triggers and develop healthy coping skills to manage anger, rather than suppressing it) for one of one sampled resident (Resident 12). This deficient practice placed Resident 12 at risk for increased anxiety and ineffective coping ability that would diminish his quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure:A Narcotic Key Controlled Release Form (a log signed by licensed nurses during shift change endorsing over responsibility for the controlled substances in the cart) was completed accurately. The Controlled Drug (medications that the use and possession of are controlled by the federal government) Record (a log containing the date, time, quantity, and nurse's signature each time a dose is administered) was completed accurately for one of five sampled residents (Resident 113). These deficient practices increased the risk of loss or diversion of controlled medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure the removal of one of one sampled resident's (Resident 10) indwelling foley catheter (a hollow tube inserted into the bladder to drain or collect urine) was documented in the resident's progress notes. This deficient practice had the potential for miscommunication, not receiving continuity of care and the potential to not receive the appropriate care and services Resident 10 needs.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure Resident 1 was free from physical abuse when Resident 2 punched Resident 1 in the face. As a result, Resident 1 sustained nasal fractures (broken bones), a nosebleed and bump on the forehead which required a transfer to the general acute care hospital (GACH) for evaluation and treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of six sampled residents (Resident 1), did not develop pressure ulcer (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence [any point of the body where the bone is immediately below the skin surface]) at the facility. The facility failed to:1). Implement its policy and procedure (P&P) titled, Pressure Ulcer Prevention which indicated, the facility should develop a care plan for residents at risk for pressure ulcers specific to the resident's risk factors (something that increases the chance of developing pressure ulcer).2). Provide care and services to promote the prevention of pressure ulcer development as indicated in its P&P titled, Pressure Ulcer Prevention. 3). [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent one of six sampled residents (Resident 1) from having unplanned severe (greater than 5 percent weight loss in one month) weight loss by failing to:Implement Resident 1's Care Plan titled, Has Potential for Nutrition Problems which indicated to monitor and document Resident 1's meal percentage consumed for each meal. Implement Resident 1's Care Plan titled, Malnourished as evidenced by Nutritional Screening Tool Score of 02, which indicated to offer supplement to Resident 1 if his intake was below 50 percent. Follow the Registered Dietician's (RD) recommendations on 7/14/2025 and 9/3/2025 to provide large-portion meals to Resident 1. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide close supervision for two of seven sampled residents (Resident 1 and Resident 2) reviewed for elopement (the act of leaving a facility unsupervised and without prior authorization) risk, by failing to ensure: 1. One-to-one (1:1- a dedicated nurse assigned to continuously observe and attend to a single resident, providing close supervision and immediate interventions when needed) monitoring every shift as indicated in the care plan. 2. The functionality of the wander guard system (a technology solution designed to detect, track, and alert staff when at high risk for elopement resident attempt to exit a designated area). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to protect the resident's right to be free from physical abuse (deliberate, aggressive, or violent behavior with the intention to cause harm), for one of two sampled residents (Resident 3) when Resident 4 physically attacked Resident 3. This deficient practice resulted in Resident 3 sustaining welts (raised, red, or skin-colored bumps that appear on the skin) to his left arm, after Resident 4 hit him with a clothes hanger.

Inspectors wroteBased on observation, interview, and record review, the licensed nursing staff failed to develop a baseline care plan addressing identified mood/behavior concerns for one of five sampled residents (Resident 2). This deficient practice had the potential for delayed provision of necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure Certified Nursing Assistant (CNA) 1 received staff training after a resident (Resident 5) accused CNA 1 of abuse during personal hygiene care. This deficient practice had the potential for CNA 1 to cause harm to residents if not properly trained regarding abuse.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Follow its policy and procedure (P&P) to replace the portable container non-antibiotic medication Emergency-Kit (E-Kit) within 48-72 hours. 2. Implement its P&P titled, Disposal of Medication and Medication-Related Supplies, which indicated to ensure accurate destruction of all medications including narcotic (drug which relieves pain and induces drowsiness, stupor, or unconsciousness) were conducted with the signature of licensed nurse. These deficient practices placed all residents at risk for not providing medication during emergency situations and had the potential of loss or diversion of controlled medication.

Inspectors wroteBased on interview and record review, the facility failed to meet the professional standards of nursing practice by failing to: 1. Properly obtain accurate orthostatic blood pressure (a form of low blood pressure that happens when standing after sitting or lying down) readings for two of two sampled residents (Residents 1 and 25). This deficient practice had the potential for Residents 1 and 25 to experience a delay in interventions if they were positive for orthostatic hypotension (low blood pressure). 2. Ensure medication, Diclofenac Sodium External Gel 1% (a medication to treat pain and inflammation), was administered to the correct site as ordered by the physician for one of five sampled residents (Resident 96). [...]

Inspectors wroteBased on interview, and record review, the facility failed to: 1. Complete initial and annual skills competencies for four of four Restorative Nursing Aide (RNA, nursing aide program that help residents to maintain their function and joint mobility) staff. This deficient practice had the potential to cause injury and worsening contractures (loss of motion of a joint) for 51 current residents who required RNA treatments. 2. Ensure their Licensed Vocational Nurse knew what the purpose of checking orthostatic hypotension (a condition where blood pressure drops significantly when a person stands up from a sitting or lying position or sits up from a lying position) was for and how to obtain blood pressure readings to check for orthostatic hypotension. This deficient practice had the potential to place residents at risk for a delay in care and services which could result in falls or injury.

Inspectors wroteBased on observation, interview, and record review the facility failed to store medications properly by failing to: 1. Ensure an unopened Lantus (a long lasting insulin [a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication]) pen, an unopened insulin vial and insulin pen of Glargine YFGN (a long lasting insulin [a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication]) were stored inside the refrigerator per manufacturer's guidelines. 2. Ensure a multi-dose medication container was clean and free from particles stored in medication cart 1. [...]

Inspectors wroteBased on interview, and record review, the facility failed to have laboratory orders implemented for three of six sampled residents (Residents 25, 42 and Resident 100) by failing to: 1. Ensure Resident 25 and Resident 42 had laboratory orders drawn as ordered by the physician. 2. Ensure Resident 100 had a Keppra (anti-seizure drug) level blood draw (a procedure in which a needle is used to take blood from a vein, usually for laboratory testing) monthly. These deficient practices caused Resident 25 and Resident 42 a delay in care and placed Resident 100 at risk for seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the dietary staff followed proper storage practices in the kitchen by: 1. Not properly closing opened bags of dry food and ensuring the dry food products were stored in containers with tight fitting lids. 2. Not dating opened multi-use containers. This deficient practice had the potential to result in the attraction of pests and contamination of food served to residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure a contingency plan (a pre-defined set of actions to be taken if an original plan fails or an unexpected event occurs) was developed and included in the Facility Assessment (a process for evaluating a facility's resident population and identifying the resources needed to provide care and services). This deficient practice had the potential for the facility to ineffectively respond during unexpected circumstances and negatively impact resident care.

Inspectors wroteBased on interview and record review, the facility failed to provide meeting minutes (notes) of the Quality Assurance and Performance Improvement ([QAPI] - a data driven proactive approach to improvement used to ensure services are meeting quality standards) program to prove three repeat deficiencies in the areas of Resident Rights, Laboratory Services, and Pharmacy Services, cited during the previous recertification survey of 2024, were discussed and evaluated. This deficient practice had the potential for repeated deficiencies and placed the residents at risk for harm if areas identified were not investigated, analyzed and ensure corrective actions or activities to improve performance were effectively implemented.

Inspectors wroteBased on observation and interview, the facility failed to ensure five wheelchairs (WC, chair fitted with wheels for transport) and one geriatric chair (a large, padded chair designed to help persons with limited mobility) were not stored outside, under the rain. This deficient practice had the potential to cause damage to medical equipment and prevent safe use of WCs and geriatric chairs for residents residing the facility.

Inspectors wroteBased on interview and record review the facility failed to: 1. Ensure a resident and/or responsible party (RP) was informed in advance, of the risks and benefits of psychoactive medication (a drug that changes brain function and results in altercations in perception, mood, consciousness, or behavior) for one of five residents (Resident 46). This deficient practice violated the residents' right to make an informed decision regarding the use of psychoactive medications.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure one of 25 sampled residents (Resident 275) participated in care planning meetings. This deficient practice violated Resident 275's rights to be fully informed of the resident's plan of care and had the potential to result in delay of care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one out of six sampled resident's (Resident 36 and Resident 224) call light was within reach. This deficient practice had the potential to result in a delay in or an inability for the residents to obtain necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 25 sampled resident's (Resident 273) preference to have a shower was honored. This deficient practice had the potential to affect Resident 273's psychosocial wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to inform and provide the Notice of Medicare Non-Coverage ([NOMNC] - a notice that indicates when your care is set to end from a skilled nursing facility) form 48 hours prior to the end of skilled nursing services to resident representative for one of three sampled residents (Resident 32). This deficient practice had the potential to result in the resident not being able to exercise his right to file an appeal and unknowingly paying for non-covered care expenses.

Inspectors wroteBased on interview and record review, the facility failed to transmit the Minimum Data Set ([MDS] - a resident assessment tool) within 14 days after completion to the Centers for Medicare and Medicaid Services (CMS) for one of 25 sampled residents (Resident 93). This deficient practice resulted in incorrect data transmitted to CMS and had the potential to affect continuity of care.

Inspectors wroteBased on interview and record review the facility failed to ensure a care plan for Seroquel (antipsychotic, class of medications that treat mental illness) or Duloxetine (antidepressant, used to treat depression [feeling of sadness and low mood] was formulated for one of 25 sampled residents (Residents 46). This deficient practice had the potential for the affected resident not to receive the care and services needed and the provision of a poor-quality care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide one of six sampled residents (Resident 104) with care and services to perform activities of daily living (ADLs, basic daily activities such as eating and transferring) by failing to provide Resident 104 with an appropriate wheelchair (WC, chair fitted with wheels for transport) for transfers and out of bed activities. This deficient practice had the potential for Resident 104 to experience a decline in overall physical and mental wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide one of three sampled residents (Resident 24), with activities outside of the resident's room. This failure caused the resident to feel isolated and lacking socializing with residents outside her room.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate services to prevent a decline in joint range of motion (ROM, full movement potential of a joint) for two out of 10 sampled residents (Resident 3 and 27) who had limited ROM by failing to: 1. Ensure Resident 3 received timely quarterly (every three months) Rehabilitation Joint Mobility Assessments (JMA) to monitor changes in joint range of motion. 2. Ensure Resident 27 had a left elbow splint was placed five days a week. These deficient practices had the potential to cause further decline in Resident 3 and Resident 27's ROM and overall quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one out of six sampled residents (Resident 57) head of bed ([HOB] -raising the head of the bed to help patients reduce the risk of aspiration in patients receiving enteral nutrition) was in proper position while the enteral tube feed ([TF]- a delivery of nutrition bypassing the mouth directed to the stomach when a patient cannot safely eat nutrition directly ) was running. This deficient practice of not having the HOB in proper position placed Resident 57 at risk for aspiration (inhalation of food, liquids, other material into the lungs).

Inspectors wroteBased on interview and record review, the facility failed to: 1. Assess the insertion site of a Peripherally Inserted Central Catheter ([PICC Line] - a flexible tube that is inserted into a vein in the upper arm and guided into a large vein above the right side of the heart) at least once every shift and change the dressing every 7 days for one of one sampled resident (Resident 21). This deficient practice had the potential for Resident 21's PICC line insertion site to develop infection and other complications.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure pain was managed for one of 25 sampled residents (Resident 224) in a timely manner. This deficient practice resulted in Resident 224 experiencing unnecessary pain.

Inspectors wroteBased on interview and record review, the facility failed to ensure one out of six sampled residents (Resident 100) orders for prescribed eye drops were carried out. This deficient practice of not following the physician orders for prescribed eye drops had the potential for worsening of Resident 100's eye conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary storage practices of foods brought to residents by family and other visitors were followed for one of three sampled residents (Resident 42) when: 1. Resident 42's personal food item was not stored per manufacturer's directions. 2. Resident 42's personal food item was not labeled according to the facility's policy and procedure (P&P) titled, Food Brought in by Visitors which indicated perishable food will be labeled, dated, and discarded after 48 hours. This deficient practice had the potential for Resident 42 to experience foodborne illness (food poisoning).

Inspectors wroteBased on interview and record review, the facility failed to document in resident clinical records, when one of 25 sampled residents (Resident 76), was sent to General Acute Care Hospital (GACH) from dialysis center (a health office/clinic for treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidneys have failed) due to unresponsiveness (a state where resident was not responding to stimuli). This deficient practice had the potential to cause delay in communication among staff and placed Resident 76 at risk of not receiving appropriate care.

Inspectors wroteBased on interview and record review, the facility failed to allow one of three sampled residents, (Resident 2), to exercise the right to refuse treatment, as indicated in the facility's operational manual, titled Resident Rights: Refusal of Treatment. This failure had the potential to cause Resident 2 to experience psychosocial harm.

Inspectors wroteBased on interview and record review, the facility failed to ensure four of four sampled residents (Residents 1, 7, 8, and 9) was treated with respect and dignity when Certified Nurse Assistant (CNA 4): 1. Acted rudely and spoke to Resident 1 in a demanding voice during care. 2. Refused to stay with Resident 7 when the resident asked the CNA to wait for her while having a bowel movement. 3. Spoke loudly towards Resident 8. 4. Spoke in a harsh tone towards Resident 9 and repositioned the resident in a fast and hurried way. This deficient practice violated the resident's rights to be treated with respect and dignity and had the potential to negatively affect the self-esteem and psychosocial well-being of the residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure Dietary staff followed proper sanitation practices in the kitchen by not sweeping and mopping the kitchen floors as indicated on the Cleaning Schedule. This deficient practice had the potential to result in attracting pests in the kitchen and contamination of food served to the residents.

Inspectors wroteBased on interview and record review, the facility failed to implement care plan intervention to monitor routinely, one of three residents (Resident 1), to prevent from leaving the facility unsupervised by failing to specify: a. The type of supervision (the act of watching) Resident 1 needed after he eloped (when a resident who is cognitively, physically, mentally, emotionally, and/or chemically impaired leaves a care-giving facility or environment unsupervised, unnoticed, and/or prior to their scheduled discharge) from the facility on 6/19/2024 and 8/24/2024. b. How often Resident 1 would be monitored (watched), daily. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement the abuse prevention program policy and procedure by not reporting an allegation of abuse for one of four sampled residents (Resident 1) to the California Department of Public Health ([CDPH]- state agency), after Family Member (FM) 1 stated Certified Nurse Assistant (CNA) 1 raised her arm to hit Resident 1. This deficient practice had the potential for under-reporting abuse incidents, delay in investigation of an abuse allegation, and placed Resident 1 and other residents at risk for further abuse.

Inspectors wroteBased on interview and record review, the facility failed to submit the results of the investigation of an injuries of unknown source to the state agency (California Department of Public Health [CDPH]) within 5 working days of the incident for one of three sampled residents (Resident 1). This deficient practice delayed the CDPH investigation of unknown source of injury of Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had an environment free of accident hazards (risk) for three (3) of 3 sampled residents (Residents 1, 2, and 3) who were smokers by failing to: 1). Ensure Resident 1 did not have a cigarette lighter on his bedside table on 5/29/2024 at 11:24 a.m. 2). Ensure Resident 2 did not have a lighter and two (2) cigarette sticks in her (Resident 2) purse on 5/29/2024 at 2:51 p.m. 3) Ensure Resident 3 did not have a lighter and 2 cigarette sticks while in the hallway, and at the bedside table on 5/30/2024 at 9:07 a.m. 4). Implement its policy and procedure (P&P) titled, Smoking: [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Abuse Prevention and Prohibition Program: Operational Manual-Abuse & Neglect, which indicated the facility should report allegations of abuse immediately, but no later than two hours. This failure delayed the investigation by the California Department of Public Health (CDPH).

Inspectors wroteBased on interview and record review the facility failed to document and implement a physician telephone order to flush urinary catheter (a tube placed in the body to drain and collect urine from the bladder), monitor characteristics of urine and document urine output for 1 of 4 sampled residents (Resident 1). These failures resulted in Resident 1 being admitted to the general acute care hospital (GACH) with bladder distention (when the pouch that holds your urine is enlarged) and infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure Resident 1 received cast/splint care for 5 months after being transferred to the SNF in accordance with professional standards of practice for one of one sampled resident (Resident 1). Resident 1 did not receive cast/splint care for 5 months after being transferred to SNF. Which resulted in Resident 1 not receiving proper cast care. These deficient practices resulted in the failure in the delivery of necessary care and services in receiving cast care, failing to implement its policy and procedures (P&P) related to cast care and accurately documenting in the initial admission assessment records.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure all smoking residents are supervised while they smoke. 2. Cigarette butts are disposed of properly. This deficient practice had the potential to cause injury to residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: A. Ensure oxygen (air) tubing were dated, labeled, and changed every seven days per policy and procedure (P&P) for three of five sampled residents (Residents 77, 102, and 276). B. Ensure Resident 110 received three liters of oxygen as per physician's order. This deficient practice had the potential for four out of five sampled resident's (Residents 77, 102 and 276), to cause respiratory infection for residents on oxygen therapy and Resident 110's receiving less oxygen than required and can negatively impact the residents health and well-being.

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 when: 1. Unlabeled/undated food was found in the refrigerator and freezer. 2. Personal belongings were found stored with kitchen and resident supplies This deficient practice had the potential to result in the residents obtaining a food borne illness.

Inspectors wroteBased on observation and interview the facility failed to: 1. Ensure one out of three dumpsters were covered. This deficient practice had the potential to result in attracting rodents to the garbage site.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: A. Ensure a resident, who was totally dependent on staff for activities of daily living (ADL) a basic skill needed to carry out tasks of everyday life) and was not able to use a regular call light, was provided with a specialized call light in the form of a pad for one Resident 275. B. Ensure the call light was within reach for Resident 29 and Resident 120. This deficient practice had the potential for three out of five sampled resident's (Resident 275, 29 and 120), not being able to summon a staff member for help as needed and at risk for delay in obtaining necessary care and services.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure Resident 44 had her blood pressure checked every six hours as ordered. This deficient practice had the potential to result in Resident 44 having a dangerously high blood pressure.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure Resident 24 received assistance with feeding as ordered by the physician. This deficient practice resulted in Resident 24 eating with her hand and had the potential to result in weight loss due to Resident 24's inability to eat properly.

Inspectors wroteBased on observation, interview, and record review the facility failed to have a medical doctors order for one of five sampled Residents (Resident 175). This deficient practice of not having a medical doctors order to cover Resident 175 right hand with a sock had the potential to cause Resident 175 psychosocial harm.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was provided with emotional support while grieving for one of one sampled resident (Resident 18). This deficient practice placed Resident 18 at risk for further depression and ineffective coping ability.

Inspectors wroteBased on interview and record review, the facility failed to act on one recommendation from the pharmacy consultant (a professional responsible for reviewing each resident's medication profile monthly to identify and report changes) from December 2023, in one of five sampled residents (Resident 32). This deficient practice of failing to respond to recommendation from consultant pharmacist had the potential to result in Resident 32 receiving unnecessary medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Remove one unopened vial of expired insulin a (medication that lowers blood sugar) from the facility's medication refrigerator room station one. 2. Remove one unopened vial of expired lorazepam (a medication indicated for treatment of anxiety) from the facility's emergency kit medication refrigerator room station two and station four. 3. Ensure routine room temperature monitoring and documentation were in place to ensure medications were within the temperature ranges as specified by the drug manufacturers, in three of three medication storage rooms. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure laboratory test ordered by the physician was completed and results available in the resident's clinical records for one of thirty-one sampled residents (Resident 275). This deficient practice had the potential to result in Resident 275 experiencing preventable complications from abnormal lab values, possibly leading to medical complications requiring hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately document the dialysis (a treatment that removes wastes and extra fluid from your blood) access type for one of two sampled residents (Resident 18). This deficient practice had the potential for Resident 18 to receive misinformation and not receiving the appropriate care and services and poor continuity of care.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Infection Preventionist (a person designated by the facility to be responsible for the infection prevention and control program) Nurse attend, participate and give findings on a regular basis to Quality Assessment and Assurance ([QAA] develop and implement appropriate plans of action to correct identified quality deficiencies) committee. This deficient practice had the potential to negatively impact resident safety and unable to monitor infection control practices and outcome of the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure humidifier (helps to relieve respiratory symptoms such as shortness of breath) was labeled and dated for one out of five Residents (Resident 34). 2. Ensure housekeeping washed their hands after removing dirty gloves. These deficient practices had the potential to cause the spread infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one out of five Residents (Resident 8) was able to open the glass door in Resident 8 room. This deficient practice of the glass door not able to easily open and closing affected the ability for Resident 8 not to be able to freely exit nor enter into Resident 8 room from the outside patio.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately conduct a baseline assessment of wounds for one out of three residents (Resident 3). This deficient practice could have potentially resulted in Resident 3 ' s wounds worsening without acknowledgement of the facility to intervene.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure (P/P) titled, Abuse Prevention and Prohibition Program, to report allegation of abuse to the state survey agency, for the two of five sampled residents, (Resident 3 and Resident 4). Resident 3 who went to Resident 4 ' s room and poured/sprinkled his urine on Resident 4, who was on bed This deficient practice resulted to the delay in the investigation by the California Department of Public Health (CDPH) and placed Residents 3 and 4, and other residents at risk for continuous abuse.

Inspectors wroteBased on interview and record review, the facility failed to provide personal hygiene and assistance with toileting for 1 of 4 sampled residents, Resident 1. This failure had the potential to result in Resident 1 lying in soiled undergarments for several hours and causing further skin damage.

Inspectors wroteBased on interview, and record review the certified nurse assistants (CNA) failed to document accurate skin assessment for 1 of 3 residents (Resident 1) who had a pressure ulcer (injury to the skin) stage 3 (full thickness of tissue loss) on the left sacrum (triangular shaped bony structure located at the base of the spine) and an unstageable pressure ulcer (full thickness loss but is covered by dead tissue) on the right sacrum for the month of September 2023. This deficient practice had the potential to cause further skin breakdown, delay treatment and place the resident at risk for infection leading to hospitalization. [...]