Marina Pointe Healthcare & Subacute

Inspectors wroteBased on interview and record review, the facility failed to ensure Interdisciplinary Team (IDT, a group of health workers from different fields that work together to make and carry out one shared care plan) meetings were conducted timely for two of two sampled residents (Resident 1 and Resident 3). This failure created the potential for Residents 1 and 3 to have delayed development of a comprehensive care plan to address their physical and psychosocial needs and wellbeing.

Inspectors wroteBased on interviews and record review, the facility failed to ensure informed consent was completed with all required elements for two of six sampled residents (Resident 2 and Resident 30). This deficient practice has the potential to result in residents receiving treatments or interventions without understanding the risks, benefits, or alternatives.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of four sampled residents' (Residents 95 and 109) call light was placed within reach. This deficient practice had the potential for Residents 95 and 109 not to be able to call for assistance and delay the assistance needed.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 5) had a completed Physician Orders for Life-Sustaining Treatment (POLST) form, when the POLST form did not include a resident or responsible party signature. This failure had the potential to result in the resident's treatment preferences and wishes not being known or honored in the event of an emergency.

Inspectors wroteBased on interview and record review, the facility failed to ensure care plans were developed for two of four sampled residents (Resident 73 and 97) when there were no care plans for Resident 73's diagnoses of anxiety (persistent and excessive worry that interferes with daily activities), Alzheimer's Disease (progressive mental deterioration) major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and bipolar disorder (mental illness that causes dramatic shifts in a person's mood, energy and ability to think clearly) and Resident 97's diagnoses of anxiety, major depressive disorder, and bipolar disorder. These deficient practices had the potential to result in delayed care and services for Resident 73's and Resident 97's health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a humidifier to the oxygenator machine for one out of one sampled resident (Resident 49). This failure had the potential to allow mucous to thicken, dry, and create a mucous plug and block oxygen to the lungs.

Inspectors wroteBased on interview and record review, the facility failed to ensure sufficient numbers of nursing aides were available on weekends to provide nursing care to 10 out of 10 sampled residents in accordance with resident care plans and assessed needs. This deficient practice has the potential to result in delayed or missed care, including delays in assistance with activities of daily living (ADL, activities such as bathing, dressing and toileting a person performs daily), timely response to call lights, increased risk for falls, skin breakdown, and decreased psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of four trash bins were covered. This failure has the potential to attract pests, such as rodents and flies, to the area.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff followed proper infection control when:a) Certified Nurse Assistant (CNA 9) and Licensed Vocational Nurse (LVN 3) did not implement appropriate use of personal protective equipment (PPE, special clothing or gear to wear to protect the body from getting sick) during care of two out of 10 sampled residents (Resident 18 and 65).b) Rehabilitative Nurse Assistant (RNA) 1 walked in the hallways wearing a disposable gown.c) Laundry Staff (L1) did not use a gown when folding clean linen or loading dirty linen and attended to the clean and dirty linen at the same time. These failures had the potential to result in residents being exposed to infectious agents and becoming ill.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents in rooms 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 21, 23, 34, 35, 36, 38, and 40 had at least 80 sq ft of living space. This deficient practice had the potential to prevent residents from moving around the room freely or store personal items. Staff may also have difficulty providing care due to limited space.

Inspectors wroteBased on interview and record review, the facility failed to implement its Policy and Procedure (P&P) titled, Unusual Occurrence (an unexpected event or accident that results in significant harm or requires significant additional measures), which indicated the facility will report unusual occurrences that threaten the welfare, safety, or health of the resident, to the California Department of Public Health (CDPH), within twenty four (24) hours, when one of five sampled residents (Resident 1), had a right shoulder fracture (broken bone). This failure delayed the investigation by the CDPH and placed Resident 1 and other residents in the facility at risk for neglect and abuse.

Inspectors wroteBased on interview and record review, for one of five sampled residents (Resident 1), the facility failed to:1). Assess and investigate Resident 1's right arm pain when a Certified Nurse Assistant (CNA) reported to a Charge Nurse.2). Investigate the note posted by a family member (FM) in Resident 1's room reminding the staff to be mindful when caring and repositioning Resident 1's right arm because of the pain. 3). Investigate when the family member notified the facility on 3/17/2026 regarding the resident's right shoulder fracture (broken bone) on 3/15/2026.4). Implement its policy and procedure (P&P) titled, Accidents and Incidents - Investigation and Reporting which indicated the nurses and / or the department director or supervisor shall promptly initiate and document investigation of the incident. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a resident-centered care plan, for one of five sampled residents (Resident 1), who had mobility deficit, requiring assistance with activities of daily living (ADLs) and who had complained of right arm pain. This deficient practice had the potential to result in providing poor quality patient care and had the potential to affect in maintaining the highest practicable physical, mental and psychosocial well-being of the resident.

Inspectors wroteBased on interviews and record review, the facility failed to ensure pain management was provided for one of five sampled residents (Resident 1). consistent with professional standards or practice. The facility failed to ensure: 1). Certified Nursing Assistants (CNA) 3 documented on a Stop and Watch form (a written statement of the situation), Resident 1's constant complains of right arm pain during movement and when it was reported to the charge nurse.2). Licensed Vocational Nurse (LVN) 2 properly assessed Resident 1's right arm pain after noting the family member's (FM) posted instruction in Resident 1's room reminding staff to be mindful when touching, moving or repositioning the resident's right arm, because of the pain.3). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Certified Nursing Assistants (CNA) 1 and 2 implemented the Enhanced Barrier Precautions (EBP, an approach to the use of personal protective equipment [PPE] to decrease transmission of multidrug resistant organisms [MDROs] when contact precautions do not apply) when providing care to two of five sampled residents (Residents 2 and 3). This deficient practice had the potential to the transmission of disease causing MDROs to other residents, staffs and visitors in the facility, affecting the health conditions and causing infections, hospitalization or death.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure titled Charting and Documentation, for one of three residents (Resident 1) when:Respiratory Therapist (RT 1) wrote a progress note on 1/6/2026 at 4:15 p.m. for an event that occurred at 4:23 p.m Licensed Vocational Nurse (LVN 1) did not document his respiratory assessment findings in Resident 1's medical record. These failures resulted in Resident 1's medical record being inaccurate and incomplete. These failures had the potential to result in delayed identification of Resident 1's change in condition, and delayed interventions.

Inspectors wroteBased on interview and record review, the facility to follow its policy and procedure (P&P) titled, Resident Going Out On Pass (OOP-short term leave from the facility) Policy, for three of three sampled residents (Resident 1, 2 and 3) by failing to:1. Ensure Residents 1, 2 and 3's OOP orders indicated whether the Residents may leave OOP without a responsible person and/or indicated the length of time the Resident may be OOP. 2. Ensure Resident 3 was assessed before and after the Resident went OOP. 3. Ensure Residents 1 and 3 had a responsible person to accompany the Residents while OOP when the physician did not specify whether the Residents may leave OOP without a responsible person. These failures had the potential to negatively affect Resident 1, 2, and 3's safety and well-being while OOP.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure (P&P), titled Bed-Holds and Returns and the Transfer/Discharge Documentation, by not providing the written Notice of Discharge and the written Notice of Bed-hold (to save the bed for 7 days) upon the residents' transfer to a general acute care hospital (GACH 1), for three of four residents (Residents 1, 2 and 3) or their family representatives. This failure had the potential to result in Resident 1, Resident 2, and Resident 3 and their representatives not knowing their rights.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Bed-Holds (when a nursing home holds [reserve] a bed for seven (7) days) when the resident goes to the hospital) and Returns, by failing to hold the sub-acute bed (specialized unit of the facility providing care and services to residents with tracheostomy [surgical opening in the neck area for breathing]) for 7 days, when one of four residents' (Resident 1), was sent to the General Acute Care Hospital (GACH 1). This failure resulted in Resident 1 not re-admitted back to the facility within the 7-day bed-hold period.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of five sampled residents (Resident 4 and Resident 5) received respiratory care and services according to professional standards, by failing to ensure: 1. Resident 4 ' s ventilator (a medical device to help a person breathe when they are unable to do so on their own) alarm (visual and/or audible warnings that alert caregivers to changes in a patient's condition or the ventilator's status) located outside Resident 4 ' s room (secondary alarm) was turned on in a timely manner. 2. Resident 5 ' s ventilator alarm located at the bedside (primary alarm) was set to high. These failures had the potential to result in a delay in care and services, respiratory compromise and death for Residents 4 and 5.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure two out of six sampled residents (Resident 67 and 147) nasal cannulas (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) were not dated and labeled. This deficient practice of not dating and labeling the nasal cannulas placed Residents 67 and 147 at risk for respiratory infection (an infection affecting the nose, throat, sinuses, airways, and lungs). 2. Ensure there were not two bags of opened and emptied bottles of water, sparkling water, iced coffee, fruit juice, and energy drinks in the laundry room next to a washing machine. This deficient practice had the potential for attracting pests to the laundry room. a. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure one of seven sampled residents (Resident 9) received supervision while smoking This deficient practice had the potential to result in Resident 9 being injured while smoking. 2. Ensure the entrance and exit doors were monitored to prevent the resident from leaving the facility unattended. This deficient practice had the potential for a resident to sustain an accidental injury while outside the facility's premises without staff supervision.

Inspectors wroteBased on interview and record review, the facility failed to 1. Provide appropriate intravenous (IV- a long thin catheter in the vein to deliver medications or fluids) care for one of three sampled residents (Resident 87) by not changing the IV dressing every 7 days and not changing the IV site every 72 hours as ordered. 2. Ensure one of three sampled resident's (Resident 5) intravenous line ([IV]- a thin, flexible tube inserted into a vein) site was labeled with the date/time of insertion. These deficient practices had the potential for Resident 87 and Resident 5 to experience complications associated with having an IV.

Inspectors wroteDuring an interview and record review the facility failed to: 1. Ensure one out of six sampled residents (Resident 69) Physician Orders for Life-Sustaining Treatment ([POLST] - a form designed to improve patient care by creating a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency) was completed. This deficient practice of not completing the POLST for Resident 69 placed the resident at risk for not receiving goods and services based on their needs.

Inspectors wroteBased on observation and interview, the facility failed to: 1. Ensure a comfortable sound level, when staff was setting off the alarm when exiting the emergency door for two of 19 sampled residents (Residents 33 and 56). This deficient practice resulted in Resident 33 and 56 feeling annoyed and not being able to sleep or rest.

Inspectors wroteBased on interview and record review the facility failed to ensure one out of six sampled residents (Resident 69) was accurately assessed for smoking. This deficient practice had the potential for the facility to not develop and implement an individualized plan of care for resident 69.

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 one of 19 sampled residents (Residents 76). This failure placed Resident 19 at risk of not having his care needs met.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure one out of six sampled residents (Resident 69) had a revised care plan (a previously established care plan for a patient that has been updated to reflect changes in their condition, needs, or response to treatment) to wear protective gear while smoking. This deficient practice had the potential to place the Resident at risk burns.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure one out of six sampled residents (Resident 6) had heel protectors on while lying in bed. This had the potential of Resident 6 not receiving the appropriate care and services.

Inspectors wroteBased on interview and record review the facility failed to: 1. Ensure one out of six sampled residents (Resident 6) staff followed physician orders. This deficient practice had the potential to cause a delay in Resident's 6 plan of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure a bottle of Pro-Stat (a liquid protein supplement) and drawer in medication cart #4 was free of a sticky substance. This deficient practice had the potential to result in cross contamination (movement of bacteria from one place to another) that could result in an infection.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure one of four sampled residents (Resident 71) had a Depakote level (a blood test to check the amount of this drug in your body) completed on the first Monday of every month per physician's order. Depakote is a drug given to control seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness). This deficient practice had the potential to result in Resident 71 not receiving appropriate dosing of his Depakote.

Inspectors wroteBased on interview, and record review, the facility failed to: 1. Ensure one of three sampled residents (Resident 87) had documentation related to the insertion and discontinuation of the intravenous (IV- a long thin catheter in the vein to deliver medications or fluids) line. This deficient practice had the potential to negatively affect the delivery of necessary care and services for Resident 87.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure residents in rooms 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 21, 23, 34, 35, 36, 38, and 40 had at least 80 sqft of living space. This deficient practice had the potential to result in residents not being able to move around freely or store personal items. Staff may also have difficulty providing care due to a lack of space.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a physician's order was obtained for ankle-foot orthotic (a device to provide support and stability to the ankle and foot, correct foot and ankle deformities, improve walking and mobility, reduce pain and inflammation, and control muscle spasms) device, before being implemented to one of three residents (Resident 1). This failure resulted in Resident 1 wearing ankle foot orthosis without an order. This failure placed Resident 1 at risk to receive inappropriate care resulting in skin breakdown and joint complications.

Inspectors wroteBased on interview, and record review, the facility failed ensure the physician's order to apply buddy strap (a hook and loop straps used to treat injured fingers by taping them to an uninjured finger) to one of three residents (Resident 1), were implemented for nine (9) days (from 1/21/2025 through 1/29/2025). The failure had the potential to delay the healing of Resident 1's right index finger (finger next to thumb) fracture (broken bone) and placed the resident at risk for complications.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe environment for one of 4 sampled residents by failing to: 1. Provide adequate supervision and implement interventions for one of 4 sampled residents (Resident 1), who verbalized wanting to go Out on Pass ([OOP] short term leave from facility) and had previous episodes of leaving the facility without an Out on Pass ([OOP] short leave from facility) physician ' s order. 2. Implement Resident 1 ' s Care Plan to monitor Resident 1 ' s behavior symptoms such as wandering, inappropriate response to verbal communication and document. 3. Accurately assess Resident 1 ' s Elopement Risk 4. Ensure the facility ' s exit doors alarms were activated and monitored. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) who was admitted in the facility with cellulitis (skin infection caused by bacteria) of the right and left lower limb (leg) received care and services to meet the resident ' s needs by failing to: 1. Ensure Resident 1 received wound treatment as ordered by the physician. 2. Complete a weekly assessment of Resident 1 ' s wound. This deficient practice placed Resident 1 at risk for worsening, complications, and poor healing of the resident ' s skin condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure all doors that lead to the outside of the facility had an alarm to prevent one of five sampled residents (Resident 1), who was assessed as a high risk for elopement, (leaving the health care facility unsupervised and undetected) from leaving the facility without staff knowledge. This deficient practice had the potential for Resident 1 to be injured while out of the facility premises without supervision from staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Certified Nursing Assistance (CNA) had the specific competencies and skill sets necessary to document and monitor three of 3 residents' (Resident 1, Resident 2, and Resident 3) meal intake percentage. This deficient practice increased the risk that Resident 1, Resident 2, and Resident 3 could have experienced undernourishment, which could result in weight loss, medical complications leading to hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to ensure three of 12 sampled residents (Resident 2, 69, and 23) medical records were updated to show documentation that advance directive's (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) were discussed and written information were provided to the residents and/or responsible parties. This deficient practice had the potential for the residents not to receive necessary information, treatments and care regarding the end of life issues according to their wishes.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure adequate supervision was provided to a resident who was at risk for falls for one of 19 sampled residents (Resident 95). 2. Ensure personal extension cord was free of electrical safety hazards for one of 19 sampled residents (Resident 71). 3. Ensure the main ventilator was plugged into an emergency back-up power outlet (red plug outlet) instead of an extension cord for one of 19 sampled residents (Resident 68).

Inspectors wroteBased on observation, interview, and record review, the facility to label the oxygen tubing weekly in accordance with the facility's policy and procedure, for two of three sampled residents (Resident 12 nad 71). This deficient practice had the potential for infection due to prolonged use of the oxygen tubing.

Inspectors wroteBased on interview and record review, the facility failed to ensure the pharmacy consultant recommendation to consider discontinuing PRN (as needed) psychotropic (drug that affects behavior, mood, thoughts, or perception) was acknowledged and acted upon for two out of five sampled residents (Resident 86, Resident 2 and Resident 43). This deficient practice for failing to respond to recommendation from the pharmacy consultant places Residents at risk for unnecessary medication administration.

Inspectors wroteBased on interview, and record review, the facility failed to provide sufficient dietetic service oversight when the dietary supervisor (DS) was overseeing three departments (housekeeping, maintenance, and dietary services) all at the same time, while registered dietitian worked on a consulting basis. This deficient practice resulted on the oversight of food safety, sanitation, and storage of food in the kitchen, lack of in-services and evaluation of competency of [NAME] 1 and [NAME] 2 on how to validate (verify that the measuring instrument continues to be suitable for its purpose) and calibrate (test its accuracy in a substance with a known temperature and adjust the thermometer to match that temperature) thermometer and had a potential to affect 77 out of 92 residents who received food from the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. Staff were following the facility's policy when checking the accuracy and calibrating the thermometer. 2. Facility failed to ensure [NAME] 1 and [NAME] 2 has the competency to validate and calibrate thermometer. These failures had a potential to result the temperatures of food are not accurate resulting to possible food borne illnesses (an illness caused by contaminated food and beverages) or growth of bacteria in food in 77 of 92 medically compromised residents who received food from the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure foods were handled, prepared, and stored in a manner that prevented foodborne illness by ensuring to: 1. Remov expired items from the walk-in refrigerator. 2. Keep food boxes off the floor. 3. Check refrigerator and freezer temperatures as scheduled. 4. Maintain the ice machine for cleanliness. 5. Keep the ice scoop outside the ice chest to prevent contamination. These failures 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 in 77 out of 92 medically compromised residents who received food and ice from the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two medications were not left at a resident's bedside table, who was not capable of self-administering oral medications, for one of 19 sampled residents (Resident 71). This deficient practice had the potential to result in unsafe medication application or omission of medication. Findings During observation, on 1/23/2024, at 9:55 a.m., Resident 71 was lying in bed watching a movie on his tablet. A medicine cup containing 5 mL of a yellow liquid was observed on the bedside table in front of the resident, along with a plastic cup of a pink liquid with powder at the bottom of it. During an interview with the resident at the same time, he stated the liquid was medication for protein and wound healing and the pink drink with powder at the bottom of the cup was for protein. [...]

Inspectors wroteBased on observation and interview the facility failed to ensure two of 19 sampled residents (Resident 23 and 35) call light device was placed within reach at all times. This deficient practice had the potential to result in a delay in or in an inability for the residents to obtain necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of three residents (Residents 36 and Resident 153) chose one of 3 billing options on the facility's SNF Beneficiary Notification form when there was a change in Medicare coverage related to skilled nursing needs. This deficient practice had the potential for residents to be unaware of their financial responsibilities for the services received at the facility, and for related standard claim appeal rights.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who had physical restraint were evaluated regularly and less restrictive measures were attempted for one of two sampled residents (Resident 31). This deficient practice had the potential to place residents at risk for unnecessary prolonged use of restraint that could lead to decline in physical functioning and residents not being treated with respect and dignity.

Inspectors wroteBased on observation, interview, and record review. The facility failed to provide accurate information in the Minimum Data Set ([MDS] resident assessment and care screening tool) for one of one sampled resident (Resident 31). This deficient practice had the potential to result inaccurate care and services for Resident 31 due to inappropriate MDS care screening and assessment tool practices.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 19 sampled residents (Residents 43), change of condition PASRR was submitted to the Department of Health Care Services (DHCS). Resident 43's level one PASRR was not resubmitted after a change of condition to ensure the resident was re-evaluated. This failure had the potential to cause harm due to not receiving care and services in the most appropriate setting for the resident's needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate and consistent activities of interest for one of one sampled resident (Resident 66). This deficient practice had the potential to decrease Resident 66's social interaction, sense of belongings, depression, and emotional health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment and services for one of two sampled residents (Resident 31) who received gastrostomy tube feedings ([GT] tube surgically placed into the stomach for nutrient and medication administration) to ensure that feeding formula was labeled in accordance with the facility's policy and procedure. This deficient practice had a potential for feeding tube formula to be outdated that could cause side-effect to resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label one medication with an open date for a floor stock or house supply in medication cart two. This deficient practice had the potential to result in the prolonged use and loss of strength of the floor stock medication.

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 15). This deficient practice had the potential for Resident 15 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's Quality Assurance Performance Improvement committee ([QAPI] takes a systemic, interdisciplinary, comprehensive, and data driven approach to maintaining and improving safety and quality in nursing homes while involving residents and families, and all nursing home caregivers in practical and creative problem solving) failed to identify facility and resident care issues, and develop and implement appropriate plans of action which included to evaluate measures to maintain resident supervision practices by having the dietary supervisor (DS) overseeing maintenance, dietary and housekeeping concerns. This had the potential to negatively impact resident safety, care and outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control measures by: 1. Failing to ensure staff was performing proper hand hygiene when going and out of a resident room. This deficient practice had the potential to transmit infectious microorganisms and increase the risk of infection and hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to meet a minimum of 80 square feet (sq. ft.) per resident in multiple resident bedrooms in the following rooms 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 21, 23, 34, 35, 36, 38, and 40. The failure to provide adequate space created the potential for adversely affecting the residents' quality of life, safety, and health, and the provision of care who occupied rooms 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 21, 23, 34, 35, 36, 38, and 40.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement reporting guidelines of All facilities Letter (AFL) 23-09, dated 1/18/2023, by failing to report the facility's COVID-19 (an infectioous disease caused by the SAR-CoV-2 virus) outbreak (at least one confirmed case of COVID-19 who had resided in the facility for at least 7 days) for 2 of 4 sampled residents (Resident 1 and Resident 2) to the California Department of Public Health (CDPH) District Office. This deficient practice resulted in the delay of the investigation by CDPH and had the potential to spread COVID-19 infection to the residents, staff, and visitors.