Live Oak Rehab Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent a fall for one (1) of two sampled residents (Resident 1) who was assessed to be dependent (helper does all of the effort, resident does none of the effort to complete the activity) with wheeling 50 feet with two turn and needed partial/moderate assistance (helper does less than half the effort; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one (1) of 1 sampled resident (Resident 1) Responsible Party (RP) was notified of a change in treatment plan. This deficient practice has the potential to affect Resident 1's right to be informed about his care.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide safety measures and supervision by not assisting, and monitoring to ensure a safe environment for Resident 1. This deficient practice not only lead to Resident 1 had skin discoloration on the left thigh but also had the potential to cause further physical harm and injuries.

Inspectors wroteBased on observation, interview and record review , the facility failed to accommodate the needs of one (1) of two (2) sampled residents (Resident 2) by failing to ensure the call light (patient-safety device, often a button on a cord, used in hospitals and nursing homes to enable patients to alert staff for assistance, thereby preventing falls and ensuring care) was within reach (arm's length of the resident or less than) of Resident 2 on 5/1/2026. This deficient practice had the potential to delay in the necessary care and services and/or needs not being met for Resident 2.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that one (1) of two (2) sampled residents (Resident 3) were provided with assistance while eating. This deficient practice had the potential for Resident 3 to experience weight loss and nutrient deficiencies.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide oxygen therapy (treatment that provides supplemental, or extra oxygen) as indicated on the physician's order for two (2) of two sampled residents (Resident 12 and 72) reviewed for respiratory and oxygen in accordance with the facility's policy and procedures (P&P) by failing to:Ensure Resident 12 received oxygen as ordered by the physician and the resident's oxygen tubing (a tubing that connects to the oxygen source used to deliver oxygen) was connected to the oxygen concentrator (a medical device that gives extra oxygen by taking and filtering air from the surroundings) was not lying on the floor. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare the correct amount of sweet and sour sauce served during lunch on 4/8/2026 in accordance with the facility's spring menu and policy and procedure (P&P). This deficient practice had the potential to result in meal dissatisfaction, decreased nutritional intake and weight loss for 81 residents.

Inspectors wroteBased on observation, interview, the facility's kitchen staff failed to ensure the chicken on the facility's menu was prepared at a safe temperature on 4/8/2026 during lunch time, in accordance with the facility's Policy and Procedure (P&P). This deficient practice has the potential to cause 81 residents to have foodborne illness (foodborne diseases or food poisoning, illnesses caused by consuming food or beverages contaminated with harmful agents).

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper food storage handling practices in accordance with its policy and procedure (P&P) by: Failing to ensure eight (8) food items were labeled with preparation date, thaw date and/ or use by date. Failing to ensure Dietary Service Supervisor (DSS) perform handwashing and change gloves after picking up an alcohol wrap from the floor and then placed a thermometer into the tray of cooked chicken on the steam table. Failing to ensure three (3) food carts were free of white splattered stains on their doors. These deficient practices have the potential to result in food born illness (any sickness that is caused by the consumption of foods or beverages that are contaminated with certain infectious or noninfectious agents) to 81 residents receiving food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) were followed in accordance with the facility's policy and procedure (P&P) when facility failed to ensure:1. Resident 3's tube feeding (the process of delivering liquid nutrition directly into the stomach or small intestine via a soft, flexible tube) machine was free of beige colored stains.2. Laundry staff followed infection control practices as evidenced by two used paper cups and paper towels left in the clean area of the laundry room, and by the presence of light brown splatter stains on the shelves where clean linens were stored.3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two (2) of 2 sampled residents (Residents 47 and 48) reviewed for environment were provided with a homelike environment by failing to maintain a scratch- free, non-discolored wall surface in the residents' room, in accordance with the facility's policy. This deficient practice had the potential for an unsafe and unclean environment and had the potential to negatively affect the residents' quality of life.

Inspectors wroteBased on interview and record review, the facility failed to protect the confidentiality of the information of one (1) of five sampled residents (Resident 38) observed during medication administration in accordance with the facility's policy and procedure when Licensed Vocational Nurse 1 (LVN 1), left the laptop screen switched on with Resident 38's electronic medication administration record (eMAR, is the digital version of the traditional paper medication administration records used in healthcare facilities) displayed on the screen. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (1) of two (2) sampled residents (Resident 47) reviewed for environment was provided a homelike environment by failing to ensure Resident 47's call light (a communication device that allows residents to alert staff for assistance) was within arm's reach, and the resident's television (TV) was plugged in, and the TV's remote control was functioning. These deficient practices had the potential to negatively affect the residents' quality of life.

Inspectors wroteBased on observation and interview, the facility failed to provide oral care for one (1) of three (3) sampled residents (Residents 103) reviewed for activities of daily living (ADL) as indicated on the facility policy. This deficient practice had the potential to cause dry mouth, infection mouth soreness, discomfort and reduce Resident 103's quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the tube feeding (TF, a medical method of delivering liquid nutrition, formula, and medications directly into the stomach or small intestine) order for one of four sampled Residents (Resident 48) reviewed for tube feeding, was administered on 4/8/2026 in accordance with the physician's order. This deficient practice had the potential to cause Resident 48 to lose weight and for his health condition to decline.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the peripherally inserted central catheter (PICC line- a long flexible catheter that is inserted through a vein in the upper arm) care was provided in accordance with standards of practice for one (1) of 19 sampled residents (Resident 100) by: Failing to ensure Resident 100's PICC line was assessed and documented upon admission. Failing to ensure the physician's telephone order to remove the PICC line (inserted from General Acute Care Hospital [GACH]) was followed. Failing to ensure Resident 100's PICC line dressing was changed upon admission and weekly as indicated in the facility's policy and procedure (P&P). These deficient practices had the potential to result in Resident 100 developing an infection on the PICC line insertion site.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure licensed staff used two (2) person identifiers (the individual's name, an assigned identification number, date of birth or another person-specific identifier) prior to administering medications to ensure the accurate acquiring, administering of drugs and biologicals to meet the needs for one (1) of 5 sampled residents (Residents 38) observed for medication administration in accordance with the facility's policy and procedure (P&P) . This deficient practice had the potential for medication errors (any preventable event that may cause or lead to inappropriate medication use) result in harm to Resident 38.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper labeling and storage of medication was provided for one (1) of five sampled residents (Resident 38) observed during the medication administration as indicated in the facility's Policy and Procedure (P&P) by failing to ensure one opened bottle of Promethazine (an antihistamine medication that prevents and treats the symptoms of an allergic reaction) was properly labeled with date opened and expiration date was legible and the Promethazine bottle was stored in a locked compartment. These deficient practices have the potential for Resident 38 to have an adverse reaction (an undesired, harmful, or unpleasant effect resulting from a medication) from the potentially expired medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the diet order for one (1) of 1 sampled resident (Residents 92) reviewed for food in accordance with the facility's policy and procedure (P&P). This deficient practice had the potential to result in choking (medical emergency that occurs when a foreign object such as food becomes lodged in the upper airway blocking airflow and preventing normal breathing) and for Resident 92 not to receive the required amount of nutrition, which could lead to weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop an individualized resident-centered care plan (a care plan that prioritizes the unique health needs and desired outcomes of the resident) with measurable objectives, timeframe, and interventions when Resident 1 was observed scooting herself off the wheelchair. This deficient practice has the potential to delay in the necessary care and services for Resident 1's which can potentially result in injury and harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect one (1) of two (2) sampled residents (Resident 1) right to be free from sexual abuse (non-consensual [without the person's permission] sexual contact of any type with a resident who does not wish to engage in sexual activity or may not have the capacity to consent) when Resident 2 was observed in Resident 1's room on top of Resident 1. Resident 2 was observed touching Resident 1's breast while kissing Resident 1 on the lips on 3/7/2026. This failure resulted in Resident 1 being sexually abused by Resident 2 on 3/7/2026 and had the potential to result in Resident 1 experiencing negative psychosocial effects (a person's mental, emotional, social and spiritual health and hopelessness).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's environment was free from accident hazards such as call light and bed control cords that could be used to wrap the resident's fingers with for one (1) of two (2) sampled residents (Resident 1). This deficient practice had the potential to result in injuries related to Resident 1's behavior of wrapping her fingers onto call light cord.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of resident- to resident abuse to local, state and federal officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) within two (2) hours, for 2 of 2 sampled residents (Residents 1 and 2) per facility policy. This resulted in a delay of an onsite inspection by the California Department of Public Health (CAPD) to ensure the alleged abuse was investigated, to protect and prevent further abuse of the residents in the facility.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that one of two sampled residents (Resident 1) had an arranged transportation to bring the resident to an outside Primary Care Physician's (PCP) appointment. This deficient practice had the potential to cause delay in treatment and worsening of Resident 1's health condition.

Inspectors wroteBased on interviews and record reviews, the facility failed to immediately inform the physician for one of two sampled residents (Resident 1), who had diagnoses that included history of falling, muscle weaknesses, dementia (a progressive state of decline in mental abilities), and abnormality in gait and mobility when Resident 1 had an unwitnessed fall on 12/23/2025. This deficient practice placed Resident 1 at risk for delayed intervention to ensure Resident 1 did not have complications from the fall such as fracture (break or crack in the bone).

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect one of two sampled residents (Resident 1) from sexual abuse (non-consensual [without the person's permission] touching of one person for the sexual gratification of another) when Resident 2 was observed on video surveillance and by a family member (Visitor 1), pushing Resident 1 down the hallway in a wheelchair and started to touch, caress and squeeze Resident 1's right and left breast while Resident 1 repeatedly pushed Resident 2's hand away on 10/7/2025 at around 12:17 PM. This deficient practice resulted in Resident 1 being sexually abused by Resident 2 while Resident 1 repeatedly pushed Resident 2's hands away from touching her breasts. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure to post accurate and updated Direct Care Service Hours Per Patient Day (DHPPD, refers to the actual hours of work performed per patient day by a direct caregiver) and Daily Posted Nurse Staffing in accordance with the facility's policy and procedure (P&P) titled Posting Direct Care Daily Staffing Numbers. This deficient practice resulted in residents and visitors not being informed of the facility census, staffing and actual hours worked by staff.

Inspectors wroteBased on interview and record review the facility failed to report an unusual occurrence (events or situations that do not happen daily or that may have had an impact on the residents) to the Department within 24 hours for one of the sampled residents (Resident 1) by failing to:a. Ensure the facility reported to the Department when the facility was made aware on 1/9/2025 of Resident 1's sustained further injury and dislocation (a disruption of the normal position of the ends of two or more bones where they meet at a joint) of the right hip in accordance with the facility's policy and procedure (P&P) titled, Unusual Occurrence Reporting. This failure had the potential to affect the health, safety, and well-being of the residents.

Inspectors wroteBased on interview and record review, the facility failed to investigate an injury of an unknown source for one of four sampled residents (Resident 1) per the facility's policy and procedure (P&P). This failure had the potential to affect the health and safety of the resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents' choices or preferences were honored for one (1) of three (3) sampled residents (Resident 1) in accordance with the facility's policy and procedure. This deficient practice had the potential to negatively affect Resident 1's self-worth, self-esteem, and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one (1) of two (2) sampled residents (Resident 1) received adequate supervision and assistance to prevent accidents and injuries, by failing to provide the assistance needed to Resident 1who was assessed to be dependent (helper does all effort needed to complete activity) to facility staff while toileting on 7/21/2025. This deficient practice resulted in Resident 1 having an unwitnessed fall and being found sitting in front of the toilet in the resident's restroom after the resident was left unattended by facility staff on 7/21/2025. Resident 1 experienced left inner thigh pain with a rating of 7 out of 10 (a tool for assessing pain intensity using scale 0 to 10, where 0 represents no pain and 10 represents the worst pain imaginable). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a care plan (a document that outlines the facility's plan to provide personalized care to a resident based on the resident's needs) for one (1) of two (2) sampled residents (Resident 1), when Resident 1 was noted to have a decline in the resident's cognitive skills (ability to understand and make decisions), mobility (ability to move or be moved) and function for Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) assistance, based on the Change of Condition Minimum Data Set (MDS - a resident assessment tool), dated 7/16/2025. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to protect the resident's right to be free from physical abuse (willful infliction of injury which includes, but is not limited to, hitting, slapping, punching, biting, and kicking) for one of two sampled residents (Resident 1). On 4/10/2025 at around 4:42 PM, Certified Nurse Assistant 1 (CNA 1) grabbed Resident 1's shirt from the back and caused the shirt to choke Resident 1 from the neck area and CNA 1 slap Resident 1's back which made a loud smacking noise. This failure resulted in Resident 1 to experience physical abuse from CNA 1 and had the potential to affect the resident's emotional, mental, and psychosocial (relating to social factors and individual thought and behavior) well-being.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure safe provision of pharmaceutical services as indicated in the facility policy by failing to: 1. Lock/secure over the counter medications (OTC, medications that can be bought without a prescription) in the facility's central supply room. 2. Lock/secure a liquid vial of Lorazepam (brand name of a controlled anxiety medication) in the medication fridge in the medication room. 3. Ensure OTC medications were kept in a locked storage room that was not accessible by non-licensed and authorized staff. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide two (2) of 2 sampled residents (Residents 61 and 82) meal trays that were appetizing and palatable (agreeable to one's sense of taste). This failure had the potential to result in dissatisfaction, decreased food intake and placed Residents 61 and 82 at risk for unplanned weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper food handling practices in accordance with its policy and procedure (P&P) by failing to ensure: 1. To discard expired food items which were stored in Refrigerator 3. 2. Staff's personal food container was not in the kitchen refrigerator. 3. Food items stored in the dry food storage were labeled with delivery and use by dates. 4. Micro-kill germicidal alcohol wipes (a powerful disinfectant solution premoistened with alcohol solution that effectively kills bacteria and viruses) and ThickenUp instant food and drink thickener (a powder based, instant thickening agent that can be used with both liquids and food to help manage swallowing difficulties) were not stored together (one area) in the kitchen, by the coffee machine. 5. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to promote dignity and respect for one (1) of 1 sampled resident (Resident 44) when Certified Nursing Assistant 6 (CNA 6) was observed standing above Resident 44's eye level while assisting the resident during mealtime. This failure had the potential to affect Resident 44's self-esteem and self-worth and violated Resident 44's right to be treated with dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow up to ensure a Level 2 Preadmission Screening and Resident Review (Level 2 PASARR, comprehensive evaluation conducted by the appropriate state-designated authority that determines whether an individual has mental disorder [MD-a health condition that affects a person's thinking, mood, behavior, or feelings], intellectual disability [ID-a condition characterized by significant limitations in both intellectual functioning and adaptive behavior that originates before the age of 22] or related condition, determines the appropriate setting for the individual, and recommends what if any, specialized services and/or rehabilitative services the individual needs) was conducted for one of one sampled resident (Resident 79) with a diagnosis of schizophrenia (serious mental illness in which people interpret reality [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to develop a comprehensive person-centered care plan (a document that outlines the facility's plan to provide personalized are to a resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs) to reflect a pharmacological intervention (refers to the administration of medication to treat or prevent a disease or illness) for pain for one of 20 sampled residents (Resident 197) in accordance with the resident's physician order. This deficient practice resulted in inadequate pain management and interventions for Resident 197.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 60), who was a non-English speaking resident had access to a communication board (a visual tool that displays pictures, symbols, or illustrations, allowing individuals with limited verbal communication abilities to express themselves by pointing to the images to convey their needs, wants, or thoughts; essentially acting as a bridge for communication through visual cues instead of spoken words.) or translation services. This failure placed Resident 60 at risk for unmet needs which may have led to increased distress and a decline in psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to provide nail care (the practice of keeping resident's fingernails clean, short, and properly trimmed) for one of one sampled resident (Resident 80), who needed total physical assistance with personal hygiene (the ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands). This deficient practice had the potential to place Resident 20 at risk for increased risk for infection, skin breakdown around the nails and potential complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess and provide specific resident preferred activities and interests for one of one sampled resident (Resident 39). This deficient practice had the potential to negatively affect Resident 39's sense of self-worth and psychosocial well-being

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of five (5) sampled residents (Resident 79), who was experiencing significant weight loss, received Restorative Nursing Assistant (RNA-helps patients regain their ability to perform daily tasks after an illness or injury. They work in long-term care settings like nursing homes and rehabilitation centers) feeding assistance as ordered by physician and that staff accurately and timely documented Resident 79's nutritional intake on 2/18/2025 and 2/19/2025. This failure had the potential for Resident 79 for inadequate nutrition and hydration (the process of replacing water in the body) causing further weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess and manage the resident's pain timely and effectively for one of one sampled resident (Resident 197) when the licensed nurses failed to: 1. Ensure the licensed nursing staff assessed Resident 197's potential to have pain after the Fentanyl patch was removed. 2. Reorder Fentanyl (a potent synthetic pain medication used to treat chronic severe pain or severe pain following surgery) five days in advance per facility policy 3. Implement Resident 197's care plan (a document that outlines the facility's plan to provide personalized are to a Resident that includes measurable objectives and timeframes to meet a Resident's medical, nursing, and mental and psychosocial needs) interventions to address and manage resident's pain. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide trauma-informed care (an approach to delivering care that involves understanding, recognizing, and responding to the effects of all types of trauma and recognizes the widespread impact and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans [a document that outlines the facility's plan to provide personalized care to resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs] to avoid re-traumatization [when stress reactions experienced as a result of a previous traumatic event are relived when faced with a new similar incident]) for one of 20 sampled residents (Resident 71) who was diagnosed with post-traumatic stress disorder (PTSD- a disorder in which a person has difficulty recovering after [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the physician's order to Give with food when administering Oyster Shell Calcium/D tablet (medication used to prevent or treat low blood calcium levels in people who do not get enough calcium from their diets) for one of two sampled residents (Resident 54). This failure increased the risk for Resident 54 to experience adverse reactions and or reduced effectiveness of the medication.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one (1) of 1 sampled resident (Resident 61) received food that accommodated resident intolerances and preference as indicated on the facility policy. This failure had the potential to result in Resident 61 having a decreased meal intake which would lead to weight loss and malnutrition (a state of nutritional deficiency or imbalance that occurs when the body does not receive or absorb sufficient nutrients [calories, protein, vitamins, minerals] to maintain health and function properly).

Inspectors wroteBased on observation, interview, and record review, the facility failed to observe infection control measures for two of eight sampled residents (Residents 49 and 299) as indicated on the facility policy by failing to ensure: 1. Resident 49's indwelling catheter drainage bag (Foley catheter- a tube that allows urine to drain from the bladder into a drainage bag) was not touching the floor. 2. Licensed nurse adhered to enhanced barrier precaution (EBP, infection control interventions, primarily used in nursing homes, that focus on reducing the transmission of multidrug-resistant organisms (MDROs) by emphasizing the use of gowns and gloves during high-contact resident care activities) policy by failing to wear a gown when handling Resident 299's feeding tube. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the visitor for one of five sampled residents (Resident 2) wore required personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) of gloves and gown while in a contact isolation (separation of residents with an infection from residents without an infection) room. This failure had the potential to spread infectious agents throughout the facility to residents, staff and/or other visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two (2) of seven (7) sampled residents (Residents 2 and 3) had call lights (one of the major communication technologies that link nursing home staff to the needs of residents) were placed within the residents' reach. This deficient practice had the potential for the delay in residents receiving care and/or risk for injury from falls if residents attempted to get out of bed on their own.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post the nurse staffing information (refers to the actual hours of work performed per patient day by a direct caregiver) at the start of each shift on 11/13/2024 in accordance with the facility policy. This deficient practice had the potential for the residents and visitors being unaware of the nursing hour and number of nurses working for each shift.

Inspectors wroteBased on interview and record review, the facility failed to have a copy of employee's vaccination cards, and an updated and accurate list of employees with COVID 19 (Coronavirus Disease 19; a respiratory viral infection that affects primarily the lungs and result in cough and difficulty breathing) vaccination for the year 2023-2024. This deficient practice placed the residents and staff at risk for possible COVID-19 infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to reasonably accommodate the needs of two of two sampled Residents (Resident 1 and 2) by failing to answer the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) timely. This deficient practice had the potential for the residents not to be able to call the staff for assistance, which could result to not receiving or delayed needed care or services necessary for the resident's well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three (1) of two (2) sampled residents (Resident 1) was free from an unnecessary psychotropic drug (any medication capable of affecting the mind, emotions, and behavior) in accordance with the facility policy and procedure by failing to ensure: 1. Resident 1 have a specific target behavior in addition to panicky feeling for the use of Ativan (Lorazepam, medication used to treat anxiety). 2. Resident 1 have a physician's order for Ativan prior to administering it to the resident on 5/5/2024. This deficient practice had the potential to place Resident 1 at risk for significant adverse (harmful) consequences from the use of unnecessary psychotropic drug.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled resident (Resident 1) was free of unnecessary physical restraint (any direct physical contact where the intention of the person intervening is to prevent, restrict, or subdue movement of the body, or part of the body of another person). On 4/1/2024 at 3:30 am, Licensed Vocational Nurse (LVN) 1 and LVN 2, tied Resident 1 with a white linen from waist down, and tied at the back of the wheelchair which restricted the resident from movement and getting up from her wheelchair. This deficient practice resulted to unnecessary restraint and placed the resident at risk of physical harm from impeding the circulation of resident's whole body from the restraint and it can also cause psychosocial harm, skin break down for Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote dignity and respect for 5 of 6 residents (Residents 16, 85, 89, 72, and 90) for dignity care area as indicated on the facility's policy when: 1. Resident 16 was found with food on her clothes, face, and hands. 2. Resident 85 was not provided privacy when he was sitting in bed wearing an incontinent brief with the privacy curtain opened. 3. Resident 89 was found with food debris on his shirt and dried white colored liquid on his chin after eating breakfast. 4. Resident 72's personal space was not protected when Resident 90 grabs Resident 72's food and/or the resident's foot. 5. Resident 90 was assisted with feeding by the staff standing over the resident (above the resident's eye level) during meal assistance. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow its Advance Directives (a written instruction, such as a living will or durable power of attorney for health care, recognized under State law relating to the provision of health care when the individual is incapable) policy for three (3) of seven (7) sampled residents (Resident 44, 68, and 251) for Advance Directive care area when: 1. Resident 44 did not have documented evidence on being informed of his choice to complete an Advanced Directive. 2. Resident 68's advance directive was not maintained in the residents' chart. 3. Resident 251's advance directive was not maintained in the residents' chart. These deficient practices have the potential not to carry out Residents 44, 68, and 251's wishes regarding health care decisions during an emergency. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop an individualized resident-centered care plan (a care plan that prioritizes the unique health needs and desired outcomes of the resident) with measurable objectives, timeframe, and interventions to meet the residents' needs for three (3) of 23 sampled residents (Residents 58, 37, and 79). 1. Resident 58 did not have a care plan to address resident's behavior of not wanting to share the shared restroom with other residents. This deficient practice can lead to worsening of resident's behavior and can affect another resident and not able to used the shared restroom. 2. Resident 37's comprehensive care plan on the use of antibiotic medication (a drug used to treat infections caused by bacteria and other microorganisms). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate treatment and services to increase, prevent, or maintain range of motion (ROM, full movement potential of a joint) by not providing restorative nursing services (a program available in nursing homes that helps residents maintain any progress made during therapy treatments, enabling them to achieve their highest practicable level of functioning) for three (3) of four (4) sampled residents (Residents 64, 63, and 15) for position or ROM care area, as ordered by the physician. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents' head of bed (HOB) was elevated above 30 to 45 degrees when receiving enteral feedings through a gastrostomy tube (GT, a tube inserted through the belly that brings nutrition directly to the stomach) for two of five sampled residents (Resident 62 and 68) for the tube feeding care area. This deficient practice had the potential for Resident 62 and 68 to aspirate (when something enters the airway or lungs by accident) which can lead to lung problems such as pneumonia (a lung infection).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary respiratory care services for two (2) of 2 sampled residents (Residents 36 and 40) for respiratory care area by failing to: 1.a. Ensure Resident 36's oxygen humidifier (a device used to make supplemental oxygen moist) was changed per physician's order. This deficient practice had the potential for Resident 36 to develop a respiratory infection. 1.b. Place a visible oxygen signage by Resident 36's door/wall prior to entering the room. This deficient practice had the potential for harm to Resident 36 and other residents, in an event of fire. 2.a Ensure Resident 40's humidifier and oxygen tubing were changed every seven (7) days per policy. This deficient practice had the potential for Resident 40 to develop a respiratory infection. 2.b. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident who received dialysis (process of removing waste products and excess fluid from the body) received care and treatment in accordance with the resident's care plan for three (3) of five (5) sampled residents (Resident 5, 14, and 20) for dialysis care area by failing to ensure: 1. A dialysis emergency kit was placed at the bedside for Resident 5 and an alert sign postage to indicate precautions on the resident's dialysis site access. 2. A dialysis emergency kit was placed at the bedside for Resident 14 and an alert sign postage to indicate precautions on the resident's dialysis site access. 3. A dialysis emergency kit was placed at the bedside for Resident 20. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide social services by not assisting and arranging care and services for two of two sampled residents (Resident 70 and Resident 79). 1. Social Services did not follow up on Resident 70's misplaced hearing aids. 2. The facility did not follow their policy to call law enforcement when Resident 70 hearing aids were missing. 3. Social Services did not follow up on Resident 79 dental services for new dentures. These deficient practices had the potential for residents to have a delay in care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label foods in the kitchen with item 'use by' date (the last date recommended for the use of the product) and failed to discard expired food as indicated in the facility's policy and procedure. 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 interview and record review, the facility failed to ensure the antibiotic stewardship program protocols for prescribing the appropriate antibiotics (medication used to treat or prevent some types of bacterial infection) was provided for eight of ten sampled residents (Resident 73, 64, 29, 87, 37, 3, 11, and 65) prior to the administration of their antibiotic therapy. 1. The facility did not complete the Surveillance Data Collection form for (Resident 73, 64, 29, 87, 37, 3) who were receiving antibiotics in March 2024. 2. The facility did not follow the surveillance data collection form prior to prescribing antibiotics for Resident 11 and 65 residents in February 2024. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to wipe down the handle of two (2) of 2 laundry washers (Washer 1 and Washer 2) with an Environmental Protection Agency (EPA, federal government agency created to protect human health and environment by providing environmental laws, and provides technical support to minimize threats) approved disinfectant solution (approved by EPA that is safe to use and at the same time effective in disinfecting the surface/ killing the bacteria to avoid spread of infection and illness) as indicated on the facility policy. This deficient practice had the potential for spread of infection to the residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the physician of a significant weight loss for one (1) of two (2) sampled residents (Residents 40) who experienced severe weight loss (weight loss greater than five [5] % in one month) for nutrition care area. This deficient practice placed Resident 40 at risk for further decline in nutritional status and continued weight loss.

Inspectors wroteBased on interview and record review, the facility failed to ensure an accurate assessment was conducted regarding the resident's active diagnoses (current diagnosis) for one of three sampled resident (Resident 19) in the resident assessment care area. This deficient practice had the potential to negatively affect Resident 19's plan of care and delivery of necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two (2) of 23 residents (Residents 4 and 37) received treatment and services to maintain or improve level of assistance needed with Activities of Daily Living (ADL), as indicated on the facility's policy: 1. Resident 4 was not provided assistance with eating. 2. Resident 37 was not provided with a communication board. This deficient practice had the potential for Residents 4 and 37's functional abilities to decline.

Inspectors wroteBased on interview and record review, the facility failed to provide audiology (audiology is the branch of science and medicine concerned with the sense of hearing. Audiologists are health care professionals who diagnose, manage, and treat hearing, balance, or ear problems) and Ear, Nose, Throat (ENT) for hearing loss in accordance with physician's order for one of four sampled residents (Resident 20) for the communication and sensory care area. This deficient practice had the potential for Resident 20 to have increased hearing loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement treatment for the prevention of pressure ulcer (painful wound caused as a result of pressure or friction) by failing to ensure that the low air loss mattress (LAL, operates using a blower based pump that is designed to circulate a constant flow of air through the mattress, commonly used to heal pressure ulcers) was on the correct settings for one (1) of two (2) sampled residents (Residents 48) for pressure injury care area, in accordance with the facility's policy and procedure. This deficient practice had the potential to place Resident 48 to be at risk for progression of pressure ulcer.

Inspectors wroteBased on interview and record review, the facility failed to act upon the consultant pharmacist's recommendation to include manufacturers recommendation for the use of Carvedilol (medication to treat high blood pressure) for 1 of 5 sampled residents (Resident 20). This deficient practice had the potential for Resident 20 to have fast absorption of Carvedilol, if not taken with food, and may suffer from the medication side effects such as feeling of dizziness or fainting when standing up.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two (2) of 5 sampled residents (Residents 44 and 19), for unnecessary medication care area, were free from the use of unnecessary psychotropic drug (any medication capable of affecting the mind, emotions, and behavior) when: 1. Resident 44 did not receive a Gradual Dose (GDR, is the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued). for the use of Mirtazapine (a medication used to treat depression [a mood disorder that causes a persistent feeling of sadness and loss of interest]). 2. There was no rationale documented by the physician for Resident 19's extended use (more than 14 days) of as needed (PRN) Temazepam (medication to treat sleep problem). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) were followed for (1) of thirteen (13) sampled resident (Resident 3) for the infection control care area in accordance with the facility's policy and procedure when: a) There was no proper sign for Contact Isolation (used for patients with diseases caused by microorganisms [bacteria and viruses] that are spread through direct and indirect contact) posted on Resident 3's door. b) Certified Nurse Assistant 2 (CNA 2) did step out of the isolation room multiple times and touched the clean linen cart then came back inside the Resident 3's room wearing the same gown. [...]

Inspectors wroteBased on interview, and record review the facility failed to designate a full-time (work 40 or more hours in a week) Infection Preventionist Nurse (IPN) per facility policy. This deficient practice had the potential for infection control practices to be unaccounted for including identifying, controlling, and containing the spread of infections within the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure call light (used in healthcare facilities as an alerting device for nurses or other nursing personnel to assist a resident when in need) was within reach for one (1) of 23 sampled residents (Resident 63) as indicated in the facility's policy and procedure and care plan. This deficient practice had the potential not to meet Resident 63's needs and preference.

Inspectors wroteBased on interview and record review, the facility failed to report to their assigned state agency (California Department of Public Health, CDPH) of an unusual occurrence of injury of unknown (source of injury was not observed by any person and origin could not be explained by the resident) origin for one out of two sampled residents (Resident 1). This failure had resulted to the facility not reporting injury of unknown origin and can place Resident 1 at risk for sustaining another injury.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the safety for one of three sampled residents (Resident 1) by not monitoring residents while in the activity room. This deficient practice resulted in Resident 1 obtaining paint from the activity cart and ingesting (swallowing) the paint.

Inspectors wroteBased on interview and record review, the facility failed to ensure one (1) of three (3) sampled Residents (Resident 3) received care with elimination/toileting in accordance with the facility's policy and procedure. This deficient practice resulted in Resident 3's diapers left wet for an extended period which could potentially result in skin irritation or skin breakdown.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three (3) of six (6) sampled residents (Residents 1, 2, and 3) was free from an unnecessary psychotropic drug (any medication capable of affecting the mind, emotions, and behavior) in accordance with the facility policy and procedure by failing to ensure: 1. Resident 1 have a specific target behavior for the use of Ativan (Lorazepam, medication used to treat anxiety). 2. Resident 2 have a physician's order for Ativan received for 17 days. 3. Resident 3 have a physician's order for Ativan received for one (1) day. This deficient practice had the potential to place Residents 1, 2 and 3 at risk for significant adverse (harmful) consequences from the use of unnecessary psychotropic drug.

Inspectors wroteBased on interview and record review, the facility failed to address the use of Ativan (Lorazepam, medication used to treat anxiety [persistent and excessive worry that interferes with daily activities]) on the medication regimen review (MRR, or Drug Regimen Review, a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) for two (2) of six (6) sampled Residents (Resident 2 and 3) in accordance with the facility policy. This deficient practice had the potential for unnecessary medication administered to Residents 2 and 3, which could result to serious harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) were followed in accordance with the facility's policy and procedure by: 1. LS failed to wipe down the handle of the washer Washer 1 with an EPA (Environmental Protection Agency, federal government agency created to protect human health and environment by providing environmental laws, and provides technical support to minimize threats) approved disinfectant solution (approved by EPA that is safe to use and at the same time effective in disinfecting the surface/ killing the bacteria to avoid spread of infection and illness) after loading the washer with soiled linens and/ or clothes. that were from the facility's red zone. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to communicate the planned discharge to the family of one of one sampled resident (Resident 1) to Skilled Nursing Facility 2 (SNF 2). This deficient practice violated Resident 1's right to be treated with respect and has the potential to have negative psychosocial outcomes for the residents.

Inspectors wroteBased on interview and record review, the facility failed to readmit one of one sampled resident (Resident 1) on 9/18/23 and did not make an effort to find out an accurate status of the resident's condition based on the facility's policy and procedure. This deficient practice resulted to Resident 1 discharge to Skilled Nursing facility 2 (SNF 2) and is in the violation of Resident 1's rights to resume residency at the facility.