Meadow Creek Post-Acute

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient licensed nursing staff to meet resident needs, as evidenced by the Facility Assessment (a required, facility wide evaluation used to align the specific needs of the resident population with the facility's resources) identifying a required night shift staffing level of one Registered Nurse (RN) and two Licensed Vocational Nurses (LVNs). This deficient practice resulted in enteral (liquid food) feedings being administered late, medications being administered late, and vital signs not being obtained by nursing staff. These failures had the potential to negatively impact residents' health and safety by delaying necessary treatments, monitoring, and identification of changes in condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of five sampled residents (Resident 35, 55 and 68 ) were free of unnecessary physical restraints (any object or device that an individual cannot remove easily which restricts freedom of movement) by failing to:1. Ensure on-going assessment and reevaluation of restraints' continuous use were conducted and documented.2. Ensure less restrictive measures were attempted prior to initiating hand mitten (soft, padded hand covers designed to prevent patients from removing medical equipment) restraints.3. Follow Physician orders to apply the peek-a-boo mitten ( a convenient mesh or cloth inspection flap, that caregivers to quickly check a resident's circulation and skin without having to remove the entire mitten) not a closed mitten restraint.4. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the following for two of four sampled residents (Resident 35 and Resident 83), including:1. Failed to develop a comprehensive person-center care plan to address Resident 35's restraints.2. Failed to develop a comprehensive person-center care plan for Resident 83's communication. These failures had the potential to negatively affect the delivery of care and services to Residents 35 and 83.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure dependent residents' received timely and appropriate assistance with activities of daily living (ADL- routine activities such as bathing, dressing, and toileting a person performs daily) care by failing to:1. Ensure four of five sampled residents (Resident 4, Resident 19, Resident 27, and Resident 42) fingernails were trimmed and free from accumulation of unknown substance underneath their fingernails. This failure resulted in Resident 4, Resident 19, Resident 27, and Resident 42 fingernails having irregular edges, accumulation of dark brown substances under the fingernails and had the potential to cause infection and impaired skin integrity.2. Ensure one of three sampled residents (Resident 58) was provided with a shower twice a week. This failure resulted in Resident 58 feeling unclean and neglected.3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff were trained and competent to meet communication needs for one of three sampled resident (Resident 83). These failures had the potential for the facility not be able to assess the skills necessary to provide nursing services to assure resident safety and to attain or maintain the highest practicable physical, mental, and psychosocial well-being of Resident 83.

Inspectors wroteBased on interview and record review the facility failed to implement infection control policies and procedures (P&P) when:a. The facility failed to educate and offer the annual influenza ([Flu] highly contagious respiratory infection) vaccine (medications used to prevent diseases usually given by injection or by mouth) to 59 out of 59 licensed practitioners (individual who is licensed or otherwise authorized by a state to provide health care services).b. The facility failed to implement the water management plan (plan that identifies hazardous conditions and steps to take to minimize the growth and spread of bacteria[germs]) thereby affecting 89 out of 89 residents. These failures had the potential to result in staff and residents contracting infectious diseases which can cause serious illness, hospitalization, and death.

Inspectors wroteBased on interview and record review the facility failed to educate and offer the 2025 to 2026 COVID-19 ((highly contagious respiratory disease caused by Coronavirus which is transmitted thru coughing, talking, sneezing and touching contaminated surfaces) vaccine (biological preparation to help your body build resistance to specific, harmful diseases) to fifty-nine out of fifty-nine licensed practitioners (individual who is licensed or otherwise authorized by a state to provide health care services). This failure had the potential to result in staff and residents contracting COVID-19 which can cause serious illness, hospitalization, and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 83) was provided an effective means of communication. This failure placed Resident 83 at risk for psychosocial isolation and unmet needs.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure one of one sampled resident (Resident 6) received respiratory tracheostomy (a surgical procedure that creates an opening in the neck and directly into the windpipe [trachea])suctioning (a critical medical procedure used to clear the trachea and lower airway of mucus, saliva, blood, or vomit when a person cannot cough effectively) every two hours as order. This failure had the potential to lead to Resident 6 experiencing respiratory distress (medical emergency characterized by difficulty breathing and low oxygen levels).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 1) received pain medication after reporting a pain level of 5 out of 10 on the pain scale (0 indicating no pain and 10 indicating the worst pain imaginable). This failure resulted in Resident 1 experiencing an increased pain level of 10 out of 10 on the pain scale, and waiting one hour before receiving pain medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nursing staff administered the correct medication dose as ordered for one of three sampled residents (Resident 41). Resident 41 had a physician's order for Zinc Sulfate (a dietary supplement to replenish an essential element, Zinc) 220 milligrams (mg, unit to measure dose), one tablet daily. Resident 41 was administered four tablets of Zinc 50 mg instead. (One tablet of Zinc Sulfate 220 mg contains 50 mg of elemental zinc.)This deficient practice created the potential for a medication error that could negatively impact the resident's health condition.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Licensed Vocational Nurse (LVN 2) did not administer Norco (hydrocodone/acetaminophen, a narcotic pain medication) to one of one sampled residents (Resident 28) when the resident's assessed pain level was 3 out of 10 level on a pain scale rating from zero to ten (pain screening tool using numerical value to assess the level of pain ranging from 0 to 3-mild pain, from 4 to 6- moderate pain, and from 7 to 9-severe pain, and 10- the worse pain possible) and did not meet the criteria established in the pain medication order. This deficient practice had the potential for significant medication errors and/or medication overdose, which could worsen the resident's health condition.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store one of forty residents (Resident 66) frozen meals in a freezer set at zero (0) degrees Fahrenheit ( F-unit of measurement) or below and the facility failed to ensure food items in the residents' refrigerator were labeled with the residents' names and not expired. These failures had the potential to result deterioration of food quality changes in texture, and loss of nutrient. Using expired food items increases the risk of bacterial growth which can cause foodborne illness (illness cause by food contaminated with bacteria, viruses, parasites, or toxins) such as nausea, vomiting (throwing up), and diarrhea (loose stool).

Inspectors wroteBased on observation, interview, and record review, the facility failed to date food brought in from an outside source and placed in a refrigerator used to keep residents' food for one out of three residents (Resident 1). This deficient practice resulted in the inability to determine the date Resident 1's food was placed in the refrigerator had the potential to cause Resident 1 food borne illness (food poisoning: any illness resulting from the food spoilage of contaminated food, pathogenic bacteria, viruses, or parasites that contaminate food, as well as toxins).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the door to the front entrance of the facility was secured after business hours (7:30 p.m. - 8 a.m.) This deficient practice resulted in the door to the front entrance of the facility being left open and unlocked by wedging a surgical mask between the door and the door frame, disabling the door's locking mechanism. This deficient practice placed residents' who resided in the facility at risk for acts of theft and harm by unauthorized individuals entering the facility and elopement (resident leaves facility without supervision).

Inspectors wroteBased on interview, and record review, the facility failed ensure a physician for one of three sampled residents (Resident 1) responded to facility staff phone calls or contacted the facility's Medical Director when Resident 1 reported symptoms of pain and burning during urination As a result of this deficient practice, Resident 1's evaluation, diagnosis, and treatment were delayed. This deficient practice placed Resident 1 at risk for worsening symptoms/infections and had the potential to turn into sepsis (a life-threatening response to an infection).

Inspectors wroteBased on interview, and record review, the facility failed to administer medication as prescribed by a physician for one of three sampled residents (Resident 1). This deficient practice resulted in Resident 1 receiving medication prescribed for a 9 a.m., administration time, but it was not administered until 10:32 a.m. This deficient practice had the potential to cause a delayed therapeutic effect.

Inspectors wroteBased on interview and record review, the facility failed to ensure Registered Nurse (RN) 1 accurately documented a prescribed treatment for one of three sampled residents (Resident 1) on the Medication Administration Record ([MAR] a daily documentation record used by a licensed nurse to document medications and treatments) when she irrigated (flush out medical device with fluid) Resident 1's indwelling catheter (thin, flexible, hollow tube inserted into the bladder to drain urine, typically into a collecting bag) with normal saline ([NS] a solution of salt and water) on 2/15/2026. This failure resulted in incomplete and inaccurate documentation for Resident 1, which prevented the facility from determining the amount of irrigating solution instilled through the indwelling catheter and verifying the corresponding drainage output relative to urine output. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident) hair was cut. This deficient practice resulted in Resident 1's hair being cut unevenly when the Beautician ([NAME]) 1 did not finish cutting Resident 1's hair. This deficient practice had the potential to negatively affect Resident 1's self-esteem and emotional wellbeing.

Inspectors wroteBased on interview and record review the facility failed to follow its policy and procedure (P&P) titled Safety and Supervision of Residents, which indicated proper resident supervision was a key part of maintaining safety, when a visitor (Family Member [FM] 2), known to pose a safety risk, was unsupervised in the facility for one of three sampled residents (Resident 1). The facility failed to ensure:1) Family Member (FM) 2, who had documented evidence of providing Resident 1 with illicit substances (drugs that are prohibited by law due to their potential for abuse, addiction, and harm) at the current facility and previous facility, was not allowed to visit Resident 1 without staff's supervision on 2/27/2026.2) Facility staff supervised FM 2's visit on 2/27/2026 rather than FM 1, who was asked to supervise the visit. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a individualized care plan for one of three sampled residents (Resident 1) addressing Resident 1's safety from Resident 1's family member (FM) 2 who had history of non-compliant with the facility's rules and interrupted Resident 1's care. This deficient practice resulted in staff not having the necessary guidance and had the potential for interruption of medically necessary care and exposure to unsafe substances (alcohol).

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident (Resident 1), who had a known allergy (when the body's immune system overreacts to something that is normally harmless like food, medicine, pollen, or pests) to cortisone (medication that helps reduce swelling, redness, and allergic reactions in the body), licensed nurses verified the allergy prior to administering hydrocortisone (medication applied to the skin to reduce swelling, redness, itching, and irritation on the skin) for one of three sampled residents (Resident 1). These failures resulted in Resident 1 receiving five doses of hydrocortisone from 2/13/2025 to 2/15/2025, placing him at risk for an allergic reaction, including swelling, difficulty breathing, and other serious complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Care Plan was created for one of four sampled residents (Resident 1) who developed redness on his penile and scrotal area. This failure had the potential for Resident 1 to have further skin breakdown, increased risk of infection, pain, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one out of three sampled residents (Resident 1) did not receive Docusate Sodium (a stool softener) and Senna (a laxative medication [softens stool or stimulates the bowels to contract] used to treat constipation [bowel movements are infrequent, hard, or difficult to pass]) while Resident 1 was experiencing diarrhea (loose watery stools). This deficient practice placed Resident 1 at risk for emotional distress, burning and irritation of the skin, worsening moisture associated skin break down (MASD, umbrella term for skin inflammation and breakdown from prolonged exposure to moisture), and dehydration (the body loses more fluids than it is taking in).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure certified nursing assistant (CNA) 3 and licensed vocational nurses (LVN) 4 were competent in caring for and reporting episodes of diarrhea (loose/ watery stool) for one out of three sampled residents (Resident 1). This deficient practice resulted in Resident 1 continuing to receive medications to induce bowel movements, during the time she was having loose stools which had the potential for emotional distress, burning and irritation of the skin, worsening moisture associated skin break down (MASD, umbrella term for skin inflammation and breakdown from prolonged exposure to moisture), and dehydration (the body loses more fluids than it is taking in).(Cross reference: F760)

Inspectors wroteBased interview, and record review, the facility failed to ensure that one of three residents (Resident 1), who was a ventilator (a machine used in healthcare to assist or perform breathing for a patient who cannot breathe adequately) dependent received personal hygiene care, including regularly scheduled showers and bed baths, to prevent maggots (a baby fly that looks like a small, white, worm without legs) infestation around tracheostomy and a Stage III pressure injury (a full-thickness skin loss that extends into the subcutaneous tissue [fat layer]) to the left lateral (relating to or situated on the side) side of the resident's neck. The facility failed to: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the immediate reporting of an incident involving neglect for one of three sampled residents (Resident 1). Resident 1, who is ventilator (a machine used in healthcare to assist or perform breathing for a patient who cannot breathe adequately) dependent, was found with maggots (a baby fly that looks like a small, white, worm without legs) present around the tracheostomy site (a surgically created opening in the neck to assist with breathing ). The facility failed to:1. Promptly report the incident to the California Department of Public Health (CDPH) as required by state regulations.2. Notify the resident's representative, who was designated to act on behalf of the resident in decision-making and to receive important health-related information. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate clinical records for one of three sampled residents (Resident 1). The facility failed to: 1. Document on Resident 1's Electronic Health Record (EHR-a digital system used to document and manage a resident's health information ) the discovery of maggots around Resident 1's tracheostomy site (a surgically created opening in the neck to assist with breathing) on 10/22/2025.2. Document a change in condition, the SBAR Situation, Background, Assessment, Recommendation (SBAR) communication tool to inform or escalate the issue to appropriate clinical staff. These deficient practices had the potential to compromise the continuity of care, delay necessary medical intervention, and negatively impact the resident's health and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that staff followed proper infection prevention and control practices while providing tracheostomy care for one of three sampled residents (Resident 3). The facility failed to:1. Ensure staff adhered to infection control protocols during tracheostomy (a surgical procedure that creates an opening in the trachea (windpipe) in the front of the neck) care (procedure involving the routine cleaning and management of a tracheostomy tube and surrounding skin to maintain airway patency and prevent infection).2. Ensure Respiratory therapist (RT) 3 was not wearing artificial (acrylic) nails while providing tracheostomy care to Resident 3 on 10/24/2025. [...]

Inspectors wroteBased on interview and record review, the facility failed to report immediately, or no later than 24 hours, an injury of unknown origin for one of three sampled residents (Resident 1). Resident 1 was found with swelling to his left elbow and an X-Ray (a procedure that takes pictures of the inside of the body to diagnose broken bones and other injuries) taken on 9/4/2025 confirmed Resident 1 had a left shoulder dislocation (an injury where the ends of bones at a joint are forced out of their normal position). Resident 1 was transferred to a General Acute Care Hospital (GACH) for further evaluation. This deficient practice resulted in the inability of the California Department of Public Health (CDPH) to investigate the injury of unknown injury in a timely manner and had the potential for facts related to Resident 1's injury to be lost and/or forgotten.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident, who used a ventilator (a machine used in healthcare to assist or perform breathing for a patient who cannot breathe adequately on their own), had a functional limitation in range of motion ([ROM] the direction a joint can move to its full potential) to both her upper and lower extremities (arms and legs) and required a two person physical assist with bed mobility, including turning and repositioning, did not sustain a facial injury for one of three sampled residents (Resident 2). The facility failed to: 1. Ensure Certified Nurse Assistant (CNA) 2 did not turn and reposition Resident 2 by herself, without assistance, placing Resident 2 on the tubing of a ventilator circuit (a system of tubes connecting a ventilator). 2. [...]

Inspectors wroteBased on interview and record review, the facility to ensure ten of ten sampled residents (Resident's 4, 5, 10, 11, 12, 13, 14, 15, 16, and 17) were provided showers on their scheduled shower day. This deficient practice resulted in incomplete personal hygiene care provided to Resident's 4, 5, 10, 11, 12, 13, 14, 15, 16, and 17, and had the potential to result in a negative impact on their quality of life and self-esteem.

Inspectors wroteBased on interview and record review the facility failed to ensure one of two sampled residents (Resident 2) received oral care. This deficient practice placed Resident 2 at risk for poor dental hygiene and increased the risk for oral infections.

Inspectors wroteBased on interview and record review the facility failed to ensure wound treatments were administered for three out of six sampled residents ( Resident 7,8,9) with pressure ulcers (localized damage to the skin and/or underlying tissue usually over a bony prominence) on 5/4/2025. This deficient practices had the potential to result in poor wound healing.

Inspectors wroteBased on interview and record review, the facility failed to cleanse and change the gastrostomy ( G- tube - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) site dressing on 5/4/2025 for three out of siix sampled residents (Residents 7, 8, 9). This deficient practices had the potential to result in G-tube site infections.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure three out of three sampled residents (Residents 67,75 and 347) self- determination was not violated when a monitoring system (contactless cardiorespiratory monitor with cloud service) with microphone and speaker was turned on without giving consent. This failure violated the rights of Residents 67,75 and 347.

Inspectors wroteBased on observation, interview, and record review, the facility accurately assesses and documented on the Minimum Data Set (MDS- a resident assessment tool) reflective of the residents' status at the time of assessment on two of five sampled residents (Resident 29 and Resident 78) by failing to: 1. Ensure Resident 29 used bilateral (both) hand mittens was accurately assessed in the MDS as a restraint (any manual method, physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement). 2. Ensure Restorative Nursing Assistant Services (RNA services performed to restore and maintain physical function of a resident as directed by their established care plan) performed for Resident 78 was documented and assessed in the MDS. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that a preadmission screening assessment ([PASRR] a federal requirement that evaluates individuals seeking admission to Medicaid-certified nursing facilities to ensure they are not inappropriately placed for long-term care) level II was done for two of 19 residents (Resident 31 and Resident 4) who was diagnosed with a mental illness schizophrenia ( a chronic mental disorder characterized by disruptions in thought processes, perceptions, emotions, and social interactions). This deficient practice had the potential for Resident 31 and Resident 4 not receiving the necessary and appropriate psychiatric level of treatment and evaluation in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to provide the necessary care and services to prevent development or worsening of pressure injury (injury to skin and underlying tissue resulting from prolonged pressure on the skin) for two of four sampled residents (Resident 53 and Resident 83). The facility failed to 1. Ensure Resident 53's skin assessment was done during shower days on Wednesdays and Saturdays and other remaining days when Resident 53 received a bed bath. 2. Ensure facility followed Resident 53's care plan titled Risk for Skin Breakdown dated 9/2023 with interventions included to turn and reposition resident at least every two hours, reassess skin daily by Certified Nursing Assistant (CNA) and weekly by licensed nurses or treatment nurse. 3. Monitor and assess Resident 83's right leg for skin breakdown. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that medication error rate was less than five percent (%). 14 medication errors out of 30 total opportunities contributed to an overall medication error rate of 46.67 percent ( %) for one of three residents (Resident 3) observed during medication administration (MedPass). The deficient practice of failing to administer medications in accordance with the physician orders increased the risk that Residents 3 may experience adverse reactions, complications, that could lead to a decline in the residents' condition, harm, or hospitalization.

Inspectors wroteBased on interview and record review the facility failed to ensure two of two sampled residents (Resident 60 and Resident 75) were aware of their rights. This failure had the potential l to violate the resident rights and had the potential to not allow the opportunity for residents to exercise their right.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow and implement its policy and procedure (P&P) regarding the use of restraints (any manual method physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement) for one of five sampled residents (Resident 29) by failing to: 1. Ensure physician order had the specific reason for the use of restraint that will benefit the resident's medical symptom. 2. Monitor and assess Resident 29's tolerance while Peek-A-Boo mittens (specialized, padded mittens used to prevent residents from pulling or interfering with medical devices) when removed. These failures had the potential to put Resident 29 at risk for unnecessary prolonged use of restraint that could lead to decline in mobility and injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR- a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) was accurately documented for one of four reviewed residents (Residents 28). This deficient practice had the potential to result in an inappropriate placement and delay of needed services for Resident 28.

Inspectors wroteBased on interview and record review, the facility failed to ensure an attempt was made to find the identity for one of one sampled resident (Resident 192) since being admitted to the facility on [DATE]. This failure had a potential to result in Resident 192 being known as John Doe not receiving adequate care and services to prevent a decline in physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure one of the one sampled, Resident 4 was treated for candidiasis (a fungal infection typically on the skin or mucous membranes caused by candida). This failure resulted in Resident 4 having an untreated oral fungal infection since 3/29/2025.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident, who had a history of pneumonia and pleural effusion and verbalized shortness of breath (SOB)/difficulty breathing at rest on 3/23/2025 at 2:13 a.m., blood pressure of 98/57 millimeters of mercury [mmHg] is unit of measurement) on 3/25/2025 at 9:48 a.m. and yellow sputum (mucus cough up from the respiratory tract) , cough, congestion (buildup of mucus in the airways, leading to difficulty breathing), lethargy ( a condition marked by drowsiness and an unusual lack of energy and mental alertness) and SOB on 3/25/2025 at 11:00 p.m. was assessed and monitored for one of four sampled residents (Resident 294). The facility failed to 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement the necessary services and care on one of four sampled residents (Resident 78) by failing to: 1. Ensure the Restorative Nursing Services ( nursing interventions that promote the residents' ability to adapt and adjust to living independently and safely) Order was being implemented and followed by restorative nursing assistant (RNA- healthcare professional who focuses on helping patients regain and maintain their physical and functional abilities after an illness or injury). 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure oral care and oral suctioning were provided to one of four sampled residents (Resident 57) when Resident 57 had dried secretions on the mouth. This failure had the potential to put Resident 57 at risk for airway obstruction (a blockage in the airway that prevents air from moving in and out of the lungs), and respiratory infection.

Inspectors wroteBased on interview and record review the facility failed to ensure the Nurse Assistant Training Program was renewed under the California department of Public Health (CDPH) licensing and certification program (L&C) denied application on [DATE]. This failure had the potential to put the residents' safety at risk when not ensuring the facility had an approved Nurse Assistant Training Program.

Inspectors wroteBased on interview and record review the facility failed to ensure an annual performance review was conducted for two of two sampled Certified Nursing Assistants (CNA 1 and CNA 2). This deficient practice had the potential for the facility not to be able to assess areas of weakness identified in performance reviews and skills necessary to provide nursing services to assure resident safety.

Inspectors wroteThe facility failed to ensure the Narcotic and Hypnotic Record have a prefilled licensed nurse signature in a designated signature box for narcotics reconciliation for one of seven facility medication carts (a mobile storage unit used in healthcare settings to safely and efficiently transport and store medications and medical supplies). This deficient practice had the potential for loss of accountability, which affected the controls against drug loss, diversion, or theft.

Inspectors wroteBased on interview and record review the facility failed to ensure one of the sampled residents (Resident 82) did not receive unnecessary psychotropic medication as needed for longer than 14 days and a new prescription required every 14 days after the resident had been evaluated. This failure had the potential to place Resident 82 at risk for adverse reactions associated with the use of psychotropic drugs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure fresh fruits were stored properly when an open container with a cantaloupe, and honeydew melon, dated fresh fruit 3/29/25 expires on 4/5/2025. This failure had the potential to expose residents to food-borne illnesses (any illness resulting from ingestion of food contaminated with bacteria, viruses, or parasites).

Inspectors wroteBased on interview and record review, the facility's Quality Assurance Performance Improvement (QAPI- a data driven proactive approach to improvement used to ensure services are meeting quality standards) failed to maintain and develop an effective plan to correct identified and potential problems by failing to: 1. To provide an effective oversight of the facility and implementation of the facility's plan of correction (POC- specific corrective actions the facility will take to address the deficiencies and the timeline for completion) of the deficient practice regarding pressure injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) and quality of care ( providing the best possible healthcare to residents focusing on safety, effectiveness, and desired health outcomes). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to observe infection control practices by failing to: a. Assess and monitor Resident 78's midline catheter (a long, thin , flexible tube inserted into a large vein in the upper arm with the tip just below the armpit used to provide venous access for medications, fluids and blood products) dressing . Resident 78's midline dressing was soiled and soaked with blood. These failures had the potential to result in the spread of diseases and infection to the facility staff, residents, and visitors.

Inspectors wroteBased on interview and record review, the facility failed to implement their protocol for Antibiotic Stewardship for one of one sampled resident (Resident 84). Resident 84 was prescribed an antibiotic drug without meeting the McGeer Criteria (a set of clinical definitions used for surveillance in long-term care facilities (LTCF) These McGeer criteria require more diagnostic information, such as positive laboratory tests, to meet the criteria for definitive infection.), after being screened for a urinary tract infection (UTI- an infection in the bladder/urinary tract). This failure had the potential to result in Resident 84 developing antibiotic resistance (not effective to treat infection) from unnecessary or inappropriate antibiotic use.

Inspectors wroteBased on interview and record review the facility failed to ensure that the facility's Certified Nursing Assistants (CNAs) were provided with approved training when their nurse assistant training program expired on [DATE]. This failure had the potential to affect the residents' quality of life due to lack of knowledge.

Inspectors wroteBased on interview and record review, the facility failed to ensure nursing staff notified the physician in a timely manner when one out of three residents (Resident 1) had blood pressure and temperature readings below the baseline, possibly leading to hypotension (low blood pressure) and/or hypothermia (abnormally low body temperature). This deficient practice had the potential of a delay in services for Resident 1 who was being monitored for sepsis prevention.

Inspectors wroteBased on interview and record review, the facility failed to ensure one out of three sampled residents (Resident 1) received consultation care for his suprapubic catheter (a thin, flexible tube that is inserted through a small incision in the lower abdomen (pubic area) into the bladder). This deficient practice had the potential for Resident 1 to become septic because of recurrent urinary tract infections ([UTI], an infection of the urinary tract, which includes the kidneys, bladder, ureters, and urethra).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sample residents (Resident 1) who had a suprapubic catheter: A. did not touch the floor while hanging on the side of the bed. B. was changed often in a timely manner. These failures had the potential to result in the transmission of infectious microorganisms to the suprapubic bag and increase risk of infection for Resident 1 who was on antibiotics for urinary tract infection ([UTI], an infection of the urinary tract, which includes the bladder, urethra, kidneys, and ureters).

Inspectors wroteBased on interview and record review, the facility failed to turn and reposition every two hours, more often as needed, one of one dependent (helper does all the effort) resident (Resident 1) who was assessed at a very high risk for developing a pressure injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence). This deficient practice increased Resident 1 ' s risk for developing a facility-acquired, Stage II (Partial-thickness loss of skin, presenting as a shallow open sore or wound) pressure injury on the right posterior lower leg area measuring 2 centimeters [(cm) unit of measurement] in length, 4 cm in width and 0.3 cm in depth.

Inspectors wroteBased on interview and record review, the facility failed to ensure sufficient nurse staffing to provide care for one of one dependent (helper does all the effort) resident (Resident 1) in the subacute unit (dedicated area within the facility that provides a higher level of intensive nursing care compared to the standard Skilled Nursing Facility care). This deficient practice resulted in Resident 1 not being turned and repositioned every two hours, increased Resident 1 ' s risk for developing a facility-acquired, Stage II (Partial-thickness loss of skin, presenting as a shallow open sore or wound) pressure injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence), and has the potential to affect thirty seven Subacute residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of eight sampled resident ' s (Resident 6), call light was answered in a timely manner. This deficient practice resulted in Resident 6, who was continent (ability to voluntarily control her ability to urinate and deficate) or bowel and bladder functions, having to urinate on herself, making her feel ignored and disrespected. This deficient practice had the potential for Resident 6 to developed skin related issues related to being left wet with urine and/or soiled with feces.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Restorative Nursing Assistant 1 (RNA 1) provided range of motion ([ROM] full movement potential of a joint) exercises and/or a splint application for two out of eight sampled residents (Residents 1 and 8). These deficient practices resulted in Resident 1 ' s order for passive range of motion ([PROM] the movement of a joint when an outside force, such as a person or machine, moves the body part while the person is relaxed) exercises to her lower extremity ([LE] leg), active assistive range of motion ([AAROM] a type of ROM exercise that involves moving an injured body part with assistance from another person or mechanical device) exercises to her bilateral (both) upper extremities ([BUE] arms), and LLE, a splint application to her right knee and Resident 8 ' s order for PROM to his BLE not being completed. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Restorative Nurse Assistant 1 (RNA 1) did not falsify records for one of eight sampled residents (Resident 1) indicating Resident 1 received RNA services that were not provided to her. These deficient practices resulted in RNA 1 documenting Resident 1 was provided seven minutes of passive range of motion ([PROM] the movement of a joint when an outside force, such as a person or machine, moves the body part while the person is relaxed) exercises, to her bilateral lower extremities ([BLE] both of her leg) and a splint (a rigid material or apparatus used to support an impaired joint) was applied to her right knee on 11/22/2024 at 2:59 p.m., when those services were not provided. [...]

Inspectors wroteBased on interview and record review, the facility failed to treat three out of four sampled residents (Resident 1, Resident 2, and Resident 3) with dignity and respect when certified nursing assistant (CNA 1) talked rudely (offensively impolite or ill-mannered) to the residents. This deficient practice had the potential to cause Resident 1, Resident 2, and Resident 3 to feel hurt, disappointed, offended, upset, angry, frustrated, and unsafe in their own home (the facility).

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled resident's (Resident 1) was not subjected to abuse by Resident 2 while left alone in the facility's dining room. This deficient practice resulted in Resident 2 physically assaulting Resident 1 by pulling Resident 1's hair while both residents were left unattended in the facility's dining room on 8/20/2024. This deficient practice had the potential for other residents who were left alone in the facility's dining room to have abusive behavior and or be subjected to abusive behavior. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident, who was assessed as being at risk for falls, did not fall and sustained multiple lacerations (a cut refers to a skin wound) required hospitalization and suturing (stitches that holds wound edges together) for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure Certified Nurse Assistant (CNA 1) asked another staff to assist transferring Resident 1 from a shower chair back to bed via a mechanical lift in attempt to remove linen and the sling from the lift underneath the resident while the resident was positioned too close to the edge of bed. 2. Ensure Resident 1's care plan titled, Self-care performance deficit included how staff will transfer the resident between surfaces to prevent falls. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled resident's (Resident 1) Permacath (a long, thin, flexible tube with surgically inserted into a vein used for short-term dialysis [procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) was not dislodged (displacement of a device thought to be securely in position) when Certified Nurse Assistant 1 (CNA 1) turned Resident 1 without assistance during care. This deficient practice resulted in approximately 400 milliliters (ml) of blood loss to Resident 1 and transfer of Resident 1 to a General Acute Care Hospital (GACH) via 911, where Resident 1 required surgical intervention on 7/23/2024 to replace the dislodged Permacath.

Inspectors wroteBased on interview, and record review, the facility failed to report an injury of unknown origin for one out of 10 sampled residents (Resident 1) when Resident 1 was assessed with a non-displaced fracture (a bone that cracks or breaks but stays in place) of the left elbow to the California Department of Public Health ([CDPH] a state agency that works to protect the health of California residents and visitors) and law enforcement. This deficient practice resulted in the inability of Resident 1 ' s left elbow fracture to be investigated by CDPH in a timely manner and had the potential for other injuries of unknown origin to not be reported by the facility.

Inspectors wroteBased on interview, and record review, the facility failed to ensure a thorough investigation was conducted when one out of ten sampled residents (Resident 1) was found to have a non-displaced fracture (a bone that cracks or breaks but stays in place) of the left elbow. This deficient practice resulted in the facility ' s inability to determine how Resident 1 ' s fracture occurred and had the potential for other injuries of unknown origin to not be investigated.

Inspectors wroteBased on observation, and interview, the facility failed to ensure the enteral feeding (a method of supplying liquid nutrients directly into the stomach) tube for one out of six sampled residents (Resident 3) was connected to Resident 3 ' s Gastric Tube ([GT] a small tube surgically inserted through the abdomen to deliver nutrition and/or medication directly into the stomach) port. This deficient practice resulted in Resident 3 ' s enteral nutrition to spill on the floor and had the potential for Resident 3 to receive the incorrect amount of nutrients that could contribute to weight loss, hunger and/or malnutrition.

Inspectors wroteBased on observation, and interview, the facility failed to ensure keys were not left on a Respiratory Therapist (medical professionals who helps patients with breathing problems) medication cart, that contained Levalbuterol Inhalation Solution (a medication used to prevent or relieve the wheezing, shortness of breath, coughing, and chest tightness), Ipratropium Bromide (a Albuterol Sulfate (a medication used to treat wheezing and shortness of breath) and Budesonide Inhalation Suspension (a medication used to decrease inflammation of the airways to make breathing easier). [...]

Inspectors wroteBased on interview and record review, the facility failed to implement their policy ensuring the accurate receiving and reconciliation (process of verifying physician orders to medication) of home medications for one of one sampled resident (Resident 1). The facility failed to track and document the date, time, or quantity of fidaxomicin (medication used to treat diarrhea caused by an infection with Clostridium difficile [bacteria that causes colitis, a serious inflammation of the colon]) when nursing staff received the medication from Resident 1 ' s Responsible Party (RP). This deficient practice had the potential for inaccurate inventory of medications causing medication shortages and underdosage of medication. [...]

Inspectors wroteBased on interview and record review the facility failed to provide sufficient staffing to accommodate two out of five residents' (Residents 1 and 2) needs by not answering call lights in a timely matter. This deficient practice could have resulted in residents not receiving needed services in a timely matter.

Inspectors wroteThe facility failed to ensure dryer's thermometer was working properly. The facility failed to monitor Temperatures of dryer. FACILITY Infection Control 04/24/24 03:39 PM Met with [NAME] Jumaoas Infection Preventionist. Has worked here since 2018. Is the full-time IP nurse and the DSD is his backup when he is not here. LVN license expires 5/31/25. IPC Resources certification and certificate of Training in Infection Prevention and Control certificate reviewed (spoke with supervisor [NAME] and states these certs are acceptable). Total hours of training was 19.75 per the CDC Nursing Home Infection Preventionist Training Course. DSD is also a certified IP LVN, had 19.75 per the CDC Nursing Home Infection Preventionist Training Course. 04/26/24 08:05 AM Entered laundry room, laundry tech mopping the floor on the dirty side in her PPE. Hand washing station located on the dirty side. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three out of 42 residents (Resident 6, 14 and 24 who were on chopped meat diet (modified diet with food prepared approximately ½ inch x ½ inch) received meat texture in form that meet their needs when cook served large chunks of meat instead of chopped meat per resident diet orders and preferences as indicated on the meal tickets. This failure had the potential to result in decreased intake related to large chunks of meat and increased choking risk.

Inspectors wroteBased on interview, and record review, the facility failed to identify, monitor, and track incidence of pressure injury ( breakdown of skin and underlying tissue due to pressure) as part of their Quality Assurance and Performance Improvement (QAPI- data driven, proactive approach to improving the quality of life, care, and services in nursing homes) activities for prevention of pressure injury in the facility by failing to: 1. Identify and monitor Resident 62's skin for pressure injury and implement action plan for reducing occurrence of pressure injury. This failure had the potential to negatively impact the care of the residents and cause delay of care and treatment for Resident 62.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the licensed nurses, in charge of resident assessment initiate a change of condition report and informed resident physician of open wound on the left buttock and the two wounds on the right inner buttock on 4/23/2024 for one of one sampled resident (Resident 62) These failures had the potential to result in Resident 62 not receiving proper treatment to Resident 62 redness on the left buttock on 4/22/2024 progressing to an open area to the left buttock (an injury that involves a break in the skin and leave the internal tissue exposed) on 4/23/2024 measuring 2.0 cubic centimeters ([cm] a unit of measurement) in length x 2.0 cm in width. Resident 62's right inner buttock with 2 small open areas one measuring 0.2 x 0.2 cm and a second one to the right inner buttock measuring 0.2x0.3 cm.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sample residents (Resident 190) received Advance Beneficiary Notice ([ABN] notice to provide information to residents/beneficiaries if they wish to continue receiving skilled services that may not be paid by Medicare and assume financial responsibility). This failure had the potential for Resident 190 to be uninformed of what services are covered.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure one of three sampled residents (Resident 62) were free from physical restraint (any action or procedure that prevents a person's free body movement to a position of choice) by placing a hand mitten restraint on the resident without a doctor's order. 2. Ensure continuous appropriate assessment and monitoring of a restraint. These failures resulted in the absence of continued assessment and monitoring of a restraint and had the potential to result in risk for complications of restraint use such as skin breakdown and severe injuries.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement a care plan for restraints(any action or procedure that prevents a person's free body movement to a position of choice) for one of three sampled residents (Resident 62). This deficient practice had the potential to negatively affect the delivery of necessary care and place the resident at risk for skin breakdown and injuries.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of five sample residents (Resident 24) was assisted out of bed to wheelchair as ordered by the physician. This failure had the potential for Resident 24 to have a further decline in physical strength and mobility.

Inspectors wroteBased on interview and record review the facility failed to ensure one of 21 sampled residents (Resident 22) was administered medication as ordered by the physician on 2/13/2024. This failure had the potential to cause Resident 22 increased dryness and inflammation of the mouth.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure: a. The licensed nurses, initiate an assessment for one of three sampled residents (Resident 62) when Certified Nursing Assistant (CNA) 5 informed licensed vocational nurse (LVN 6) of Resident 62' redness on the buttocks. b. Treatment was initiated for Resident 62's open wound on the left buttock and the two wounds on the right inner buttock on 4/23/2024. These failures had the potential to result in Resident 62 not receiving proper treatment to Resident 62 redness on the left buttock on 4/22/2024 progressing to an open area to the left buttock (an injury that involves a break in the skin and leave the internal tissue exposed) on 4/23/2024 measuring 2.0 cubic centimeters ([cm] a unit of measurement) in length x 2.0 cm in width. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate care and services to maintain and improve range of motion for two of five sample Residents ( Resident 9 and Resident 42) are provided by failing to: 1. Ensure Restorative Nursing Assistant (RNA- assist the patient in performing task that restore or maintain physical function)Services consisting of passive range of motion( PROM- someone is physically stretching or moving a part of body) on both upper extremities (arm, forearm, wrist and hand) and bilateral lower extremities( legs from the hip to the toes) as tolerated five times a week as ordered was provided to Resident 9. 2. Ensure Resident 42 who had limited mobility received RNA Services after being readmitted to the facility under hospice care. [...]

Inspectors wroteDuring an interview and record review the facility failed to ensure safety precautions were implemented on one of 21 sampled residents (Resident 21) when Resident 21 fall back on the reclining high back wheelchair (a reclining high back wheelchair designed to allow the backrest to tilt back or recline). The facility failed to: 1. Ensure Certified Nursing Assistant (CNA) 3 and night shift staff were trained on how to use the reclining high back wheelchair. 2. Provide Resident 21 an appropriate wheelchair for her size and what she was used to transport in the past. These failures resulted in Resident 21 falling back on the high back wheelchair and was transferred to general acute care hospital (GACH) on 2/28/2024 and treated for left and right shoulder contusion (a bruise in the muscle by a direct, blunt blow), head injury and neck strain.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of 21 sampled residents Resident 140's oxygen humidifier (devices that add moisture to supplemental oxygen) was changed weekly. This failure had the potential to result in Resident 140 developing a respiratory infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 70) who received hemodialysis ([HD], a medical procedure to remove fluid and waste products from the body), had an appropriate supply available inside an emergency kit. This failure had the potential for delayed intervention during accidental bleeding from the hemodialysis site for Resident 70.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of one medication cart (a movable piece of equipment used in healthcare facilities to store, transport, and dispense medicines, medical supplies, and emergency equipment.) was locked. This deficient practice resulted in resident's, visitors, and other staff having immediate access to medications and had the potential for theft, loss, and unauthorized consumption of medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one resident's (Resident 1) Power of Attorney/Responsible Party (POA 1) was informed immediately after Resident 1 had an abnormal blood glucose (a blood sugar level less than 140 milligrams [mg, one thousandth of a gram]/deciliter [dL, a metric unit of capacity] is considered normal) reading of 444 mg/dL on 3/28/2024 at 9 p.m. This deficient practice resulted in the POA/responsible party being unaware of Resident 1's elevated blood glucose and had the potential for the POA/responsible party's inability to ask questions regarding to Resident 1's plan of care.

Inspectors wroteDuring an observation, interview and record review, the facility failed to ensure one of one direct care staff, Respiratory Therapist 1 (RT1), followed infection control policies when RT 1: a. Failed to doff (remove) a used glove after exiting resident care areas of Resident 6 and 7, walking in the hallway, and touching bedside equipment for Resident 8 and 9; and b. Failed to perform hand hygiene prior to exiting Resident 6 and 7's room, prior to entering Resident 8 and 9's room, and prior to donning (putting on) new gloves. These deficient practices had the potential to result in cross contamination (physical transfer of germs from one person, object, or place to another) that could be harmful to the residents' health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure a care plan was developed and implemented for one of five sampled residents (Resident 1) after the responsible party 1 (RP 1) reported that Resident 1 was assisted during peri care (washing private areas) with water that was too hot. This deficient practice resulted in the lack of interventions and left Resident 1 unmonitored for potential skin complications that may occur from being exposed to hot water during incontinence care.

Inspectors wroteBased on interview and record review, the facility failed to ensure monitoring was implemented for one of five sampled residents (Resident 1) when the responsible party 1 (RP 1) reported that Resident 1 was provided with peri care (cleaning the private parts) using water that was too hot. This failure left Resident 1's skin condition unmonitored for potential skin complications that may occur from being exposed to hot water during incontinence care.

Inspectors wroteBased on interview and record review, the facility failed to ensure three of three licensed nurses (charge nurse 1[CN 1], licensed vocational nurse 2 (LVN 2) and Registered Nurse Supervisor [RNS 1]) knew the location of glucagon (an emergency medication used to increase blood sugar). This deficient practice had the potential to result in the provision of inadequate care and services for residents who suffer from hypoglycemia (low blood sugar), a potentially fatal complication of diabetes (condition that affects how the body processes sugar).

Inspectors wroteBased on interview and record review, the facility failed to confirm the physician received the urinalysis (urine test to check for infections of problems, UA) results for one out of three sampled residents (Resident 1). This deficient practice had the potential to result in an untreated infection which can lead to sepsis (blood infection).

Inspectors wroteBased on observation, interview and record review the facility failed to ensure one of four sampled residents (Resident 2)received the necessary treatment services by: a. Failing to ensure Resident 2 ' s toenails were trimmed and failing to address Resident 2's red big toe on the right foot. b. Failing to assist to schedule a follow-up appointment with an endocrinologist (a medical specialist who treats people with a range of conditions including diabetes[disease that affect how the body uses sugar]). This deficient practice had the potential for Resident 2 ' s to experience delay of care and treatment due to lack of assessment and follow up.

Inspectors wroteBased on interview and record review , the facility failed to ensure Prolia (injectable medicine to treat osteoporosis[disease that weaken the bones] at high risk for fracture[broken bones]) was continued and administered for one of three residents (Resident 1) as prescribed by the physician. This failure resulted in omission of Prolia ' s dose and had the potential to increase the risk of fracture for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to secure the personal belongings for one of three sampled residents (Resident 1). This deficient practice resulted in facility misplacing Resident 1 ' s iPad( small tablet computer) and had the potential to negatively affect Resident 1 ' s psychosocial wellbeing.