Lawndale Healthcare & Wellness Centre LLC

Inspectors wroteBased on interview, and record review, the facility failed to create a comprehensive person-centered care plan (CP) for Resident 1's change of condition (CoC) on 6/22/2026 in accordance with the facility's policy and procedure (P&P) titled Change in Condition and Person-Centered Care Planning. This deficient practice had the potential to result in Resident 1's medical condition to worsen.

Inspectors wroteBased on interview, and record review, the facility failed to follow the facility's policy and procedure (P & P) titled Telephone Orders, regarding one of three residents' (Resident 1) change of condition (COC) on 6/22/2026 by failing to: Follow the attending physician's (MD) recommendations of monitoring edema, monitoring for changes in swelling, pain or skin integrity. Document orders for MD's recommendations. Document monitoring of edema, changes in swelling, pain and skin integrity. This deficient practice had the potential to cause Resident 1's medical condition to worsen.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Director of Staff Development (DSD) and nursing staff did not sign the In-service/Meeting (on-going education program designed to ensure staff maintained necessary skills and training on resident safety, care quality and regulatory compliance) Sign-In sheets when the DSD did not provide the education or training and staff did not attend the In-service. This deficient practice had the potential to result in staff providing resident care without proper training or competencies, which places residents at risk for improper care and adverse outcomes.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure for 52 of 56 medically compromised and vulnerable residents who received food from the kitchen: Ensure personal water bottle were not kept at dry storage area. Ensure opened disinfecting wipes were not kept at dry storage area. Ensure expired food items were removed from the kitchen area. Ensure test strips used to test sanitation strength were not expired. These failures had the potential to result in harmful bacteria growth and cross contamination (a transfer of harmful bacteria from one place to another or one object to another) that could lead to foodborne illness (an illness caused by food contaminated with bacteria, viruses, and other toxins).

Inspectors wroteBased upon interview and record review, the facility failed to: 1. Follow its' policy and procedures for the testing of Legionella (a serious type of pneumonia caused by Legionella bacteria found in [NAME] environments that can thrive in human-made water systems) and other opportunistic waterborne pathogens within the facility's water systems. This deficient practice had the potential to cause residents and staff to become ill with Legionnaire's disease or other opportunistic waterborne pathogens.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure: 1. Registered Nurse (RN) 2 was competent in securing medication and preparation when administering medications to Resident 27. 2. The facility failed to ensure annual competencies were dated and completed for five out of six randomly selected staff members. These deficient practices had the potential for staff not securing medications, providing accurate medications to the residents and inconsistent competency assessments.

Inspectors wroteBased upon observation and interview, the facility failed to:1. Ensure resident rights were protected from a noisy environment caused by Resident 25 yelling and screaming for one of six sampled residents (Resident 52). This deficient practice resulted in a violation of resident rights.

Inspectors wroteBased on observation, interview, and record review, the facility failed to:Ensure one out of 14 sampled residents (Resident 6) was provided a homelike environment and did not have chipped paint on the bathroom door. This deficient practice of not providing a homelike environment for Resident 6 had the potential to negatively impact her quality of life.

Inspectors wroteBased upon observation, interview and record review, the facility failed to: 1. Report to the California Department of Public Health (CDPH- the state department responsible for public health in California) of an abuse allegation for one of three sampled residents (Resident 16). This deficient practice resulted in a delay of an onsite inspection by CDPH and had potential to place residents at risk for abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to:Ensure a physician order to wear lumbosacral orthosis ([LSO] - a back brace that supports the lower spine and sacrum (large, triangular bone at the base of the spine) when out of bed was followed for one of one sampled resident (Resident 38). This deficient practice had the potential to place Resident 38 for increased pain and muscle spasms.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure low air loss mattresses settings were correct for one of six sampled residents (Resident 1). This deficient practice had the potential to result in further skin breakdown.

Inspectors wroteBased on interview and record review, the facility failed to:Ensure smoking assessment was completed accurately for one of one sampled resident (Resident 38). This deficient practice had the potential to place Resident 38 at risk for injury and inadequate care planning.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure two liters of oxygen was administered as ordered by physician for two of ten sampled residents (Resident 1 and Resident 23). This deficient practice had the potential to place residents at risk for not receiving oxygen therapy as prescribed by the physician and complications such as decreased breathing drive (result of too much oxygen in the body reducing the urge to breathe) and carbon dioxide retention (less breathing resulting in less carbon dioxide exhalation and increase of carbon dioxide in blood). a. During a review of Resident 1's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to:Ensure one of one sampled resident (Resident 6) was evaluated by a physician initially in the first 90 days of admission and document his visit in resident's clinical records. This deficient practice had the potential for Resident 6's current medical condition not timely assessed by a physician that can lead to delay in necessary care and treatment.

Inspectors wroteBased upon observation, interview and record review, the facility failed to: 1. Ensure appropriate medication treatment was administered for one of six sampled residents (Resident 25) who was observed yelling loudly throughout various shifts for 4 days. This deficient practice had the potential to result in escalation of behavioral issues.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were administered at the time of preparation for one of three sampled residents (Resident 27). This failure had the potential to place resident at risk for medication errors.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were secured and visible to registered nurse administering medications for one of three sampled residents (Resident 27). This deficient practice had the potential to result in safety issues such as unauthorized resident access to medications and medication errors.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Implement the physician's orders to draw laboratory tests (a medical analysis of a body sample (blood, urine, tissue) to check health, diagnose diseases and monitor chronic conditions) for two of two sampled residents (Residents 5 and 9). This deficient practice had the potential to result in the delay of identification of medical concerns, delaying the care and services necessary for the affected residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure one of one sampled resident (Resident 38) was referred to Dental service for readjustment of his dentures. This deficient practice had the potential to result in inability to chew food and weight loss for Resident 38.

Inspectors wroteBased upon observation, interview and record review, the facility failed to: 1. Ensure resident identifiable documentation was accurate for one of six sampled residents (Resident 25). This deficient practice had the potential to negatively impact Resident 25's psychological needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of three sampled residents (Resident 1 and Resident 6), were protected from incidents of abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, deprivation by an individual, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being, including various forms such as physical [any intentional act of force that causes harm, injury, or trauma to another person's body] and sexual [any sexual activity or contact imposed on a person without their consent, often involving force, coercion, or exploitation of vulnerability] abuse), by failing to: 1). [...]

Inspectors wroteBased on interview and record review, the facility failed to report allegations of sexual and/or physical abuse to the California Department of Public Health (CDPH), for two of three sampled residents (Residents 1 and 6) when: Resident 1 informed the facility that Resident 2 entered her room, lowered his pants, kissed her and touched her vagina on 12/19/2026. Resident 6 informed the facility that Resident 2 hit him on his leg and told him (Resident 6) he wanted to suck his penis on 12/19/2026. This deficient practice resulted in a delay in investigation by the CDPH and placed Resident 1 and Resident 6 at risk for continued abuse. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Resident 2's incidents of abuse abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, deprivation by an individual, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being, including various forms such as physical [any intentional act of force that causes harm, injury, or trauma to another person's body] and sexual abuse [any sexual activity or contact imposed on a person without their consent, often involving force, coercion, or exploitation of vulnerability]) on two of three sampled residents (Resident 1 and Resident 6) were investigated, as indicated in the facility's policy and procedure (P&P) titled, Abuse Prevention and Management. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 3), was provided quality care and services, and assistance with activities of daily living, necessary to ensure the resident was kept clean, dry and comfortable. This failure placed Resident 3 to experience feelings of neglect, anger and sadness. This failure placed Resident 3 at risk of skin breakdown.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its infection prevention and control measures for one of three sampled residents (Resident 3) by failing to ensure: Certified Nurse Assistant (CNA) 2 replaced/doffed (remove) gloves, and performed hand performed hand hygiene (washing hands or using an alcohol-based hand sanitizer) during incontinence (lack of voluntary control over urination and/or defecation) care for Resident 3. This deficient practice had the potential to result in cross contamination (transfer of harmful bacteria or viruses from one place, object or person to another) and increased the risk of transmitting disease-causing organisms leading to illness for residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure a written room change with a reason was provided for one of 4 sampled residents (Resident 1). This deficient practice resulted in Resident 1 losing his bed while in the hospital.

Inspectors wroteBased upon interview and record review, the facility failed to: 1. Ensure one of 4 sample residents (Resident 1) was readmitted to the facility after being admitted to the General Acute Care Hospital. This deficient practice resulted in Resident 1 not being re-admitted to the facility and prolonging his GACH stay (four days).

Inspectors wroteBased upon interview and record review, the facility failed to: 1. Ensure one out of 4 sampled residents was readmitted to the facility after being hospitalized (Resident 1). This deficient practice resulted in Resident 1 staying in the hospital for 30 days.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Grievances and Complaints which indicated the facility would promptly review, investigate and resolve grievances and complaints for one out of three sampled residents (Resident 1). This failure had the potential for unaddressed and unresolved grievances for Resident 1 and had the potential to negatively affect the resident's quality of life and safety.

Inspectors wroteBased on interview and record review, the facility failed to ensure pain management was effective for one of three sampled residents (Resident 1) by failing to: 1. Thoroughly assess and reassess Resident 1 when the resident complained of 4 out of 10 pain (pain rating reference: 1-4=mild pain, 5-7=moderate pain, 8-9= severe pain, 10=excruciating pain) 2. Administer pain medication and/or provide non-nonpharmacological interventions (techniques other than medications to alleviate pain) as ordered by the physician. This failure had the potential to leave Resident 1 with unresolved pain and had the potential to negatively affect Resident 1's physical, mental, and psychosocial wellbeing.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a functional call device (a device used by residents to communicate their needs to staff) for two out of three sampled residents (Residents 1 and 2). This failure had the potential to result in a delay in care for Resident 1 and Resident 2 and the resident ' s needs not being met.

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient staff for resident care and safety for one of 30 sampled residents (Resident 7). This deficient practice caused a delayed response to care for Resident 7 after Resident 7's fall and the potential to affect the entire facility. Findings During a review of Resident 7's admission Record, dated 3/23/2025, the admission Record indicated Resident 7 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including muscle weakness (decreased strength in the muscles), glaucoma (an eye disease that gradually damages the optic nerve and can lead to blindness), and legal blindness (a significant level of vision loss). During a review of Resident 7's History and Physical (H&P), dated 3/6/2025, the H&P indicated Resident 7 did not have the capacity to understand and make decisions. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation practices in the kitchen when: 1. The cook (Cook 1) and dietary aid (DA) were not wearing a mask while plating breakfast trays. 2. The DA did not change gloves when returning to the tray line (a system of food preparation, used in hospitals, in which trays move along an assembly line) after touching non-food items. These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness for residents who received food from the kitchen. 3. Expired foods were stored in the kitchen and accessible for use while preparing foods. [...]

Inspectors wroteBased on observation and interview, the facility failed to implement infection control interventions to prevent the spread of germs in accordance with the facility's Respiratory Protection Program policy and procedure (P/P) impacting 57 of 57 residents and staff, with the improper wear of a N95 (a type of filtering facepiece respirator designed to provide protection from inhaling certain airborne particles) Respirator Mask while in a resident care area. This deficient practice had the potential to lead to the spread of COVID 19 (infectious disease caused by the SARS-CoV-2 virus) to residents and staff.

Inspectors wroteBased on interview and record review, the facility failed to perform an accurate fall assessment for one of 17 residents (Resident 49) after a fall. This deficient practice had the potential to result in Resident 49 to have recurrent falls and could have lead to improper care planning.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a care plan for three of four sampled residents (Resident 43 and Resident 44 and Resident 12) by failing to: 1. Develop a care plan for Resident 43's Restorative Nursing Assistance (RNA) services. 2. Develop a care plan for the use Resident 44's antipsychotic (class of medications used to treat mental illness) medication Risperdal (type of antipsychotic medication that treats 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]). 3. Implement a care plan addressing Resident 12's fingernails. [...]

Inspectors wroteBased on interview and record review, the facility failed to create a care plan timely for the use of side rails for one of 30 sampled residents (Resident 7). This deficient practice had the potential to cause Resident 7 to not have the appropriate interventions in place. Findings During a review of Resident 7's admission Record, dated 3/23/2025, the admission Record indicated Resident 7 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including muscle weakness (decreased strength in the muscles), glaucoma (an eye disease that gradually damages the optic nerve and can lead to blindness), and legal blindness (a significant level of vision loss). During a review of Resident 7's History and Physical (H&P), dated 3/6/2025, the H&P indicated Resident 7 did not have the capacity to understand and make decisions. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 30 sampled residents (Resident 12) was provided care and services to maintain good grooming and personal hygiene. This deficient practice resulted in Resident 12 not receiving nail care and had the potential to cause an infection or injury from the long fingernails. Findings During a review of Resident 12's admission Record, dated 3/23/2025, the admission Record indicated Resident 12 was admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy (a change in how the brain works due to a chemical imbalance in the blood), spinal stenosis (a condition when the space inside the backbone is too small), and type 2 diabetes mellitus (a chronic condition when the body cannot use insulin correctly and sugar builds up in the blood). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of seven residents (Resident 43 and Resident 44), with limited range of motion (ROM, the extent of movement of a joint), received restorative nursing program (designed to improve or maintain the functional ability of residents) care five times a week daily as indicated in the physician order. This deficient practice had the potential to place Residents 43 and 44 at increased risk for ROM decline.

Inspectors wroteBased on interview and record review, the facility failed to provide side rails as ordered for one of 30 sampled residents (Resident 7). This deficient practice caused Resident 7 to fall and had the potential to cause Resident 7 to have injuries from the fall. Findings During a review of Resident 7's admission Record, dated 3/23/2025, the admission Record indicated Resident 7 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including muscle weakness (decreased strength in the muscles), glaucoma (an eye disease that gradually damages the optic nerve and can lead to blindness), and legal blindness (a significant level of vision loss). During a review of Resident 7's History and Physical (H&P), dated 3/6/2025, the H&P indicated Resident 7 did not have the capacity to understand and make decisions. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the pureed diet (diet that involves consuming foods that are blended, mashed, or strained to a smooth, pudding-like consistency, making them easier to swallow for individuals with chewing or swallowing difficulties) recipe during breakfast by serving liquid consistency French toast. This deficient practice had the potential to result in inadequate nutrition status and placed the residents at a high risk of choking (person can not breath due to blocked airway).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light was within reach and accessible for one out of one sampled resident (Resident 8) who needed assistance. This deficient practice resulted in Resident 8 feeling unheard and forgotten while screaming for assistance.

Inspectors wroteBased on interview and record review the facility failed to: a. Monitor one of three sampled resident ' s (Resident 2) behaviors while the resident was on Risperidone (a psychotropic medication, used to treat certain mental/mood disorders). b. Document one of three sampled resident ' s (Resident 2) indication for an increased dose of Depakote [medication used to treat (bipolar disorder, a chronic mental health condition characterized by significant and persistent shifts in mood, energy, and activity levels)] These failure had the potential to result in inconsistent behavior monitoring and placed Resident 2 at risk for not receiving the necessary interventions for increased psychiatric behaviors.

Inspectors wroteBased on interview and record review the facility failed to protect one of three sampled residents' (Resident 2) right to be free from physical abuse. This failure resulted in Resident 2 slapping Resident 1 on the left side of the face.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement intervention in a resident's care plan titled Comprehensive Person-Centered Care Planning, which indicated hourly visual monitoring should be conducted to one of seven sampled residents (Resident 2), who was at risk for wandering(walking aimlessly)/ eloping (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). This deficient practice resulted in Resident 2 wandering into other resident ' s rooms and placed Resident 2 at risk for an altercation with another resident.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the call light for one of seven sampled residents (Resident 1) was placed within reach while Resident 1 was in bed. This deficient practice had the potential to cause Resident 1 to not be able to get the help she needed in a timely manner.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three of 11 residents (Residents 1, 2 and 3) who were smokers, had an environment free of accident hazards (risk) by failing to ensure: 1). Resident 3 was not holding a lighter while coming out of his room on 7/2/2024 at 2 p.m. 2). Resident 2 did not have a lighter on her wheelchair seat while in the room, on 7/2/2024 at 1:50 p.m. 3). Resident 1 did not have a cigarette lighter in her purse on 7/2/2024 at 1:45 p.m. These failures had the potential for Residents 3, 2, and 1 to turn on the lighters, cause a fire and affect the health, safety, and wellbeing of all 56 residents in the facility, staff and visitors and result in serious injuries, hospitalization, and death. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a comprehensive person-centered care plan (a written plan of care developed by the resident's medical provider, the interdisciplinary team ([IDT] group of healthcare professionals working together to provide residents with needed care), and the resident to help resident achieve his or her treatment goals) was developed and implemented for the safe storage of smoking materials (cigarettes and lighters) for three of three sampled residents (Residents 3, 2 and 1), who were smokers by failing to ensure: 1). Resident 3 was not holding a lighter while coming out of his room on 7/2/2024 at 2 p.m. 2). Resident 2 did not have a lighter on her wheelchair seat while in the room, on 7/2/2024 at 1:50 p.m. 3). Resident 1 did not have a cigarette lighter in her purse on 7/2/2024 at 1:45 p.m. 4). [...]

Inspectors wroteBased on interview and record review, the facility failed to: 1. Implement its abuse policy and procedure titled Reporting Abuse, indicated the facility should report any resident-to-resident altercations to the State Survey Agency and Ombudsman within 2 hours for one of three sampled residents (Resident 1). This deficient practice placed Resident 1 and other residents in the facility at risk for further abuse.

Inspectors wroteBased on interview and record review, the facility staff failed to notify the physician for one of six sampled residents (Resident 2), when Resident 2 continued to refuse to take her medications: 1. Remeron (antidepressant, medication used to treat depression) 2. Buspirone (antianxiety, medication used to treat anxiety) 3. Seroquel (antipsychotic, medication used to treat schizophrenia) This deficient practice resulted in Resident 2's physician being unaware of Resident 2's change of condition, delayed medical intervention and Resident 2 experienced unnecessary hostile behavior.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was free from verbal abuse for one of six sampled residents, (Resident 1). This deficient practice had the potential for Resident 1 to have psychological distress and caused Resident 1 to experience feelings of humiliation and disrespect.

Inspectors wroteBased on interview and record review, the facility failed to provide the State Survey Agency (Bureau of Health Facility Licensing, Certification and Resident Assessment, within the Department of Public Health), a written report of findings for the investigation of an allegation of abuse within five (5) working days for an incident of verbal abuse for one of six samples residents, (Resident 1). This deficient practice had the potential to result in unidentified abuse in the facility and failure to protect residents from further abuse.

Inspectors wroteBased on interview, and record review, the facility failed to implement the baseline care plan for one of six sampled residents, (Resident 2) by failing to: 1. Monitor Resident 2's psychotropic (drug that affects behavior, mood, and thoughts) medications side effects every shift. 2. Monitor Resident 2's mental status closely and report changes to the physician. 3. Assess Resident 2's for signs of distress or anxiety (feeling fear, afraid, and worry). These deficient practices had the potential to result in inconsistent implementation of the care plan that could lead to a delay or lack of delivery of care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents have the right to be free from verbal abuse for one of three sampled residents (Resident 1). This deficient practice had the potential for Resident 1 to have psychological distress.

Inspectors wroteBased on interview and record review, the facility staff failed to timely report the allegation of verbal abuse regarding one of three sampled Residents (Resident 1) to the facility Administrator (ADM), and to other officials including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities. These deficient practices had the potential to place Resident 1 at risk of further abuse, and neglect.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure Resident 1 was being monitored for wandering (a person that roams around and becomes lost or confused about their location) throughout the facility. 2. Ensure staff followed Resident 1's Care Plan (CP) titled Resident is an elopement risk/wanderer related to dementia (a decline in memory, language, problem-solving and other thinking skills that affect a person ' s ability to perform everyday activities) with intervention requiring a sitter for constant monitoring for safety purposes. 3. Ensure staff followed Resident 1's CP titled Risk for harm, other directed behavior potentially causing harm (episodic). Resident 1 enters other residents rooms, takes, and moves their personal items. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure (P&P) titled Abuse-Prevention, Screening, and Training Program, which indicated facility did not condone any form of resident abuse or neglect, for one of three sampled residents (Resident 1), after Resident 2 hit Resident 1. This deficient practice placed Resident 1 at risk for further abuse.

Inspectors wroteBased on interview and record review, the facility failed to report within two (2) hours, resident to resident allegation of physical abuse (Resident 2 hitting Resident 1 on the face and right eye with a wooden back scratcher) to the Department of Public Health, Licensing and Certification unit (CDPH), for one of three sampled residents (Resident 1). This failure resulted in the delay of investigation by the Department of Public Health and placing Resident 1 at risk for further abuse and psychosocial harm.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure a care plan (the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) was formulated for three of 15 sampled residents (Residents 17, 24, 27 and 54). This deficient practice had the potential for the affected residents 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: 1. Ensure expired diced tomatoes and candy sprinkles discarded after expiration date. 2. Ensure produce, seasonings, milk, mocha mix, tomato sauce, lemon juice, mayonnaise, mustard, dressings, ice cream, shakes, frozen vegetables, and pasta were labeled with received date and use by date. 3. Ensure personal staff food items were not stored in the refrigerator and dry storage room. 4. Ensure the ice machine was clean. These deficient practices had the potential to result in pathogen (germ) exposure to residents and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead to other serious medical complications and hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure a peripheral catheter ([IV], a thin tube inserted into a vein for therapeutic purposes such as administration of medications, fluids and/or blood products) dressing was dated and kept clean for one of one sample resident (Resident 24). This deficient practice had the potential for the IV insertion site to develop an infection and/or hospitalization for Resident 24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure respiratory care consistent with professional standards of practice when two of three sampled residents Resident 21 and Resident's 24 oxygen (air) nasal cannula (a device used to deliver supplemental oxygen) tubing, and humidifier (liquid that moistens the air) bottle was not labeled with the date of change. These failures had the potential to result in unsafe use or storage of oxygen equipment, respiratory infection, and/or hospitalization for Resident 21 and Resident 24. 2. Ensure oxygen precaution sign was posted on the door for one of three sampled residents (Resident 21) who was receiving oxygen. This failure had the potential to place residents at risk of injury due to a fire hazard.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure there was a physician's order for oxygen (air) therapy for one of three sampled residents (Resident 24). 2. Ensure there was a physician order for the placement, and assessment of a peripheral catheter ([IV], a thin tube inserted into a vein for therapeutic purposes such as administration of medications, fluids and/or blood products) for one of one sampled resident (Resident 24). These failures had the potential to result in unnecessary procedures and/or hospitalization for Resident 24.

Inspectors wroteBased on interview and record review, the facility failed to implement its abuse policy and procedure (P&P) titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating to ensure an allegation of abuse was reported to the California Department of Public Health (CDPH) within two hours, for one of three sampled residents (Resident 1). This deficient practice resulted to the delay in the abuse (monies) investigation by the CDPH and placed Resident 1 at risk for continuous abuse at the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set ([MDS] a standardized care assessment and care screening tool) significant change in status was completed within the required time frame for one of three sampled residents (Resident 3) This deficient practice had the potential to negatively affect the provision of necessary care and services.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to develop a comprehensive person-centered plan of care for three of twelve sampled residents (Resident 10, Resident 11, Resident 12) to monitor oxygen used via nasal cannula {(medical device that provides oxygen (colorless, odorless, tasteless gas essential to living organisms)}, whom had an order for continuous and as needed oxygen used. This deficient practice had the potential to decrease blood oxygen leading to possible re-hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility staff failed to provide knowledgeable treatment following professional standards of practice by failing to: 1. Verbalized the amount of chest compression per minute for a Cardiopulmonary resuscitation (CPR) (emergency procedure consisting of chest compressions to manually preserve intact brain flow) and ambu bag (provide positive pressure ventilation to patients who are not breathing or not breathing adequately) used according to American Heart Association (AHA) recommendations of 100-120 chest compressions per minute 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure a Licensed Vocational Nurse (LVN) 1 had an active professional nursing license before the start of his employment orientation. 2. Ensure a Licensed Vocational Nurse (LVN) 1 had a competency skill (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics in performing that an individual need to perform work roles or occupational functions successfully) check prior to orientation or upon hire. 3. Ensure a Licensed Vocational Nurse (LVN) 1 did not sign the Individual Narcotic (a drug that in moderate doses dulls the senses, relieves pain, and induces profound sleep but in excessive doses causes stupor, coma, or convulsions) Record form without a valid professional nursing license. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure a Licensed Vocational Nurse (LVN) 1 had an active professional nursing license before the start of his employment orientation. 2. Ensure a Licensed Vocational Nurse (LVN) 1 had a competency skill (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics in performing that an individual need to perform work roles or occupational functions successfully) check prior to orientation or upon hire. 3. Ensure a Licensed Vocational Nurse (LVN) 1 did not sign the Individual Narcotic (a drug that in moderate doses dulls the senses, relieves pain, and induces profound sleep but in excessive doses causes stupor, coma, or convulsions) Record form without a valid professional nursing license. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Residents 3) had develop a baseline care plan addressing vaginal bleeding. This deficient practice had the potential to negatively affect the delivery of nursing care and medical interventions to Residents 3.