National City Post Acute

Inspectors wroteBased on observation, interview and record review, the facility failed to provide respiratory care services (professional services for residents with breathing problems) in accordance with professional standards of practice for two of 10 residents reviewed for oxygen use when:Resident 1's oxygen equipment was not set up correctly by a licensed healthcare provider, and Resident 2's humidifier (water attached to oxygen machine to provide moisture to the delivered oxygen) was empty. This failure had the potential to further compromise the respiratory status of the residents.

Inspectors wroteBased on interview, and record review, the facility failed to notify the California Long-Term Care Ombudsman Program (advocacy for skilled nursing facility residents) of emergent hospital transfers and the facility failed to notify and obtain confirmation from residents within 24 hours regarding their bed hold policy, for two of 16 sampled residents (Resident 1 and Resident 2)These deficient practices placed two residents at risk for loss of their bed hold rights, lack of advocacy (the act of speaking up) support, and potential inappropriate discharge or inability to return to the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure documentation of written information regarding formulating an advanced directive and the right to accept or refuse medical treatment was provided to 9 of 10 sampled residents (6, 9, 25, 33, 34, 60, 62, 78 and 89). This failure had the result for residents to not have the opportunity to express wishes for care if capacity for decision making was lost and the right to accept or refuse treatment. FindingsOn 12/18/25 a review of Resident 6's clinical record was conducted. Resident 6 was admitted to the facility on [DATE] per the facility's admission Record. The facility did not have documentation that information regarding an Advance Directive was provided to Resident 6 or Resident 6's representative. On 12/18/25 a review of Resident 9's clinical record was conducted. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a clean and homelike environment was provided for eight residents (51, 53, 92, 45,100, 95, 34, 31). This deficient practice had the potential to reduce comfort, feelings of security, and well-being for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement resident-centered written care plans for 4 of 19 residents (92, 5, 95, and 60) when:1. Resident 92 kept perishable food routinely at her bedside and a care plan was not developed to address the behavior.2. Resident 95's severe weight loss was not care planned timely.3. Resident 5's care plan was not implemented when the resident's heel protector (device used to prevent pressure ulcer development) was not applied.4. Resident 60's left upper arm edema (fluid retention/swelling) was not care planned. As a result of these deficient practices, residents were at risk for not receiving care and treatment. Cross reference F686 and F580.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and effective pharmaceutical services when:1. Licensed Nurse (LN) 1 administered Geri Tussin DM (cough syrup containing dextromethorphan, a cough suppressant, and guaifenesin, an expectorant - loosens mucus) to Resident 52 instead of Geri Tussin (cough syrup containing guaifenesin), which was ordered. This failure had the potential to expose Resident 52 to additional side effects and slow her recovery. 2. Controlled medications (medications with a high abuse potential) for pain were not administered as ordered for one of five sampled residents (Resident 6). This failure had the potential for Resident 6 to experience harmful effects and negative health outcomes from the controlled medication. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure refrigerated medications were stored under proper temperature controls in two of two Medication Rooms. This failure had the potential to negatively alter the drugs' stability, physical properties (such as consistency) and effectiveness, which could result in adverse resident outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow appropriate infection prevention and control practices when:1. Tuberculin test (TB) was not done annually for Resident 5.2. The Licensed Nurse did not perform hand hygiene when dispensing medications.3. The back shower room and a shower chair was not clean and disinfected according to facility's cleaning schedule. In addition, the shower stall was not disinfected between residents' use. As a result of these deficient practices, residents, staff, and visitors were placed at risk for contracting infections.3. On 12/16/25 at 10:55 A.M., a joint observation and interview was conducted with certified nursing assistant (CNA) 6 in the back shower room. The back shower room was observed with two shower stalls with a wet musty smell. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 19 residents (Resident 5), who was cognitively impaired, had a representative (responsible party, RP) designated. This failure had the potential for Resident 5 not to have the opportunity to have a representative make decisions on their behalf.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light for one of 19 residents (Resident 8) was within reach. This deficient practice had the potential for Resident 8 to not have his needs met.

Inspectors wroteBased on interview and record review the facility failed to ensure the physician was notified of a resident's change of condition (COC) in a timely manner for one of two residents (Resident 95) reviewed for nutrition. As a result, Resident 95's severe weight loss was not reported to the physician in a timely manner which had the potential to delay the resident's care and treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one out of five sampled residents (Resident 6) was free from unnecessary psychotropic (affecting brain activities associated with mental processes and behavior) medication when Resident 6 was prescribed a psychotropic medication as needed for more than 14 days. This failure had the potential for Resident 6 to receive an unnecessary psychotropic medication which can lead to side effects, such as sedation and falls, and a decline in psychosocial (how a person feels about themselves and their environment) well-being.

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of transfer to a resident's responsible party (RP) and the Long-Term Care Ombudsman for one of three residents (Resident 97) reviewed for closed records. This deficient practice had the potential for the Resident 97's RP to not be aware of the resident's rights pertaining to transfers. FindingsOn 12/18/25 a review of Resident 97's clinical record was conducted. Resident 97 was admitted to the facility on [DATE] per the facility's admission Record. A review of Resident 97 Alert Charting dated 9/17/25 indicated the resident was assessed to have an acute change in level of consciousness (a crucial neurological indicator of a patient's arousal and awareness) and was transferred to the hospital for evaluation. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure it completed a pre-admission screening and resident review (PASARR) and appropriately referred one of two residents (Resident 8), reviewed for PASARR, after the resident was newly diagnosed with schizophrenia (a mental disorder characterized by paranoia and psychosis) while residing in the facility. As a result of this deficient practice, there was the potential Resident 8 required specialized services that he did not have access to.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the use of a heel protector (pressure ulcer prevention device) as ordered by the physician and identified on the care plan for one of two residents (Resident 5). This deficient practice had the potential for the resident to be at risk for pressure injury and skin breakdown.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory services were provided according to acceptable standards of practice for two of two residents (55, 60) when:1. Resident 55's nasal cannula (device delivering oxygen into the nostrils) and oxygen tubing were not changed per facility's protocol.2. The director of business development (DBD) picked Resident 60's nasal cannula off the floor and placed it into the resident's nostrils. These deficient practices had the potential to place the residents at risk for respiratory infection and compromised oxygen therapy effectiveness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the cook was competent to carry out dietary functions according to standards of practice when the cook did not prepare pureed foods according to the recipe. This failure had the potential to create a choking hazard, lessen nutritional value, and contribute to weight loss for the 12 residents on a pureed diet.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food that accommodated a resident's preference for one of 19 sampled residents (Resident 34). This failure had the potential to affect Resident 34 appetite and meal intake and lead to frustration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow appropriate infection prevention and control practices when:1. There was an expired box of tomatoes stored in the refrigerator.2. [NAME] (CK) 1 did not perform hand hygiene between gloves changes. These failures had the potential to result in foodborne illness to an already vulnerable population.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure documentation in the medical record was complete and accurate for 2 of 19 residents (95, 17) when:1. There was no documentation the nurse communicated Resident 95's condition and obtained a new order for megace (appetite stimulant) from the provider.2. Non-applicable and irrelevant additional medication directions were attached to Resident 17's levothyroxine (medication for underactive thyroid). As a result, the rationale could not readily be determined for the treatment that was provided to Resident 95. In addition, there was the potential to cause confusion during medication administration for Resident 17.

Inspectors wroteBased on interview and record review the facility failed to ensure one of five residents sampled (Resident 5) received the influenza vaccine in accordance with the Center for Disease Control (CDC) recommendations and facility policy. This failure had the potential to place Resident 5 at risk for acquiring, transmitting, or experiencing complications from influenza (a contagious respiratory illness caused by influenza viruses that infects the nose, throat, and sometimes lungs).

Inspectors wroteBased on interview, and record review, the facility failed to accurately code a fall incident on the Minimum Data Set (MDS - a federally mandated resident assessment tool) for one of three sampled residents (Resident 4). This deficient practice placed Resident 4 at risk for ineffective care planning, monitoring of fall risks and inaccurate health status sent to the federal database.

Inspectors wroteBased on interviews and record reviews, the facility failed to follow proper infection control procedures for one of five sampled residents (Resident 1) to prevent the spread of pediculosis (lice-tiny, parasitic insects [about the size of a sesame seed] that feed on blood in the scalp/skin and cause intense itching that can lead to open sores and infection) when the facility failed to assess, screen, or monitor exposed former and new roommates during a room change. This deficient practice placed four residents (Resident 1's roommates) at risk for undetected lice and possible outbreaks (further spread) in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice when Licensed Nurses (LNs) failed to consistently follow physician's order related to eye drop therapy for one of one sampled resident (Resident 1) reviewed for ophthalmic (eye) medication. This failure had the potential to place Resident 1 at risk of vision loss and blindness.

Inspectors wroteBased on interview and record review, the facility failed to provide a sufficient number of staff to answer call lights and deliver personal care in a timely manner for three of four sampled residents (1, 3 and 4), and six residents identified in the resident council meeting minutes. As a result, there was the potential for residents not to get their minimum daily care needs met.

Inspectors wroteBased on observation and interview, the facility failed to ensure a clean, safe and comfortable homelike environment when insects were observed in a resident ' s room and the screen of the sliding door was in disrepair. These failures had the potential to negatively impact the residents' health and well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to identify in a timely manner the development of pressure injuries (skin damaged by lack of movement for staying in a position for too long) for one of three sampled residents reviewed for pressure injuries/ wounds. In addition, the facility did not consistently provide treatments for Resident 1 ' s existing surgical wounds in his right foot. As a result, Resident 1 developed a new pressure wound on his coccyx (tailbone). In addition, Resident 1 ' s surgical wounds in his right foot did not heal properly, developed an infection and eventually Resident 1 underwent an amputation (surgical removal of a limb) of his right leg.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four residents (Resident 3) received food that accommodated her food preferences. This failure had the potential for Resident 3's wishes to be ignored. In addition, this failure had the potential to result in decreased food intake and weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a pain medication (med/s) was available for one of three sampled residents reviewed for pain management (Resident 1). This failure had the potential to cause the resident unnecessary pain, negatively affecting the resident's quality of life.

Inspectors wroteBased on interview and facility documents review, the Licensed Nurse (LN) 1 failed to verify a provider's discharge plan related to opioid (powerful pain-reducing medications, an example is hydrocodone/ acetaminophen) medication upon discharge for one of three sampled residents (Resident 1). The lack of communication between the provider and the facility's LNs had the potential for miscommunication with the transition of care to the receiving facility for Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to safely transfer one of five residents reviewed for pain (Resident 51) from the bed to the wheelchair, using a gait belt. As a result, Resident 51 sustained a fracture to the left humerus (shoulder). In addition, Resident 51's fistula (a site used for dialysis[a treatment to remove waste products from the blood]) was unusable, requiring Resident 51 to be hospitalized for the placement of a new dialysis access site.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow isolation precautions when contact droplet isolation (a type of isolation requiring a gown, gloves, mask and eye protection prior to entering the room) was delayed for one resident (Resident 48) with Covid-19. This failure had the potential to place residents and staff at risk of exposure to Covid-19 and cause the spread of infection.

Inspectors wroteBased on observation, interview and record review, for one of one resident reviewed for falls (Resident 25), the facility failed to ensure: 1. Adequate supervision and close monitoring were provided; and 2. Effectiveness of interventions were evaluated, and new interventions were implemented to address resident's behavior of getting up unassisted and prevent further falls. These failures resulted to Resident 25 to have five repeated falls in 2022 while at the facility. The resident's 5th incident of fall on September 20, 2022, resulted in Resident 25 sustaining left hip fracture (broken bones), and was transferred out to acute hospital for further evaluation and surgery.

Inspectors wroteBased on interview and record review, the facility failed to ensure written information regarding formulating an Advance Directive (AD - a written instruction such as a living will, relating to the provision of treatment and services when the individual is unable to make decisions) was provided to the residents and/or the resident's representative (RR), for nine of 10 residents reviewed for Advance Directive (Residents 15, 25, 40, 58, 61, 78, 82, 83, and 284). This failure had the potential for the residents to not be aware of their right to formulate an AD.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure expired food items were not stored in the refrigerator, readily available for use. This failure had the potential to result in foodborne illness to an already vulnerable facility population.

Inspectors wroteBased on interview and record review, the facility failed to ensure the PASRR (Preadmission Screening and Resident Review - a federally required document to ensure residents are appropriately placed for services) was coded accurately for diagnosis of mental illness, for one of one resident reviewed for PASRR (Resident 40). This failure had the potential for Resident 40 to not receive the care and necessary services under the appropriate setting.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive care plan for oxygen administration, for one of one resident reviewed for oxygen use (Resident 6). This failure had the potential to negatively impact the resident's quality of care and had the potential for staff to not be aware of the resident's care needs and provide appropriate treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications and medical supplies were labeled and stored according to the facility policy and manufacturer's guidelines, when: 1. The pharmacy label on the medication bubble pack did not match the physician's order on the Medication Administration Record (MAR), for one of 11 residents reviewed during the medication administration observation (Resident 236). This failure had the potential to result in Resident 236 to not receive the correct frequency and dosage of the medication prescribed by the physician; 2. One opened vial of tuberculin testing solution (test for tuberculosis - lung infection) was not labeled with a date when it was opened, and readily available to administer. This failure had the potential to not be able to determine the effect and potency of the tuberculin testing solution; and 3. [...]

Inspectors wroteBased on observation, interview, and dietary document review, the facility failed to ensure the lunch menu was followed on 8/9/19. This failure had the potential for residents to have their nutritional status compromised when they were served food items they were not expecting, or did not like.

Inspectors wroteBased on observation and interview, the facility failed to ensure food was consistently served at an appetizing temperature for 6 out of 12 residents interviewed during a confidential group interview. This failure to serve food at an appetizing temperature may result in decreased food intake resulting in weight loss, and could further compromise the nutritional status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored and prepared in a safe/sanitary manner and in accordance with standards of practice when: 1. Resident ice cream and cake were not properly covered when stored. In addition, ready to use produce was slimy and moldy. 2. Food and beverages were not properly dated and labeled. 3. Meat was not defrosted according to acceptable standards of practice. 4. Dietary staff did not consistently use gloves in the tray line while plating food. Failure to ensure safe and effective food service operations may result in exposing resident food to cross contamination and bacterial growth which may result in foodborne illness. Foodborne illness may further compromise the medical and nutritional status of the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's (18) bedroom was clean, comfortable, and homelike. This failure had the potential to negatively impact Resident 18's quality of life.

Inspectors wroteBased on interview and record review, the facility failed to conduct an IDT care conference after each MDS assessment for 2 of 18 sampled residents (48, 73). As a result, there was a potential for resident care issues to not be addressed.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's (66) narcotic (a controlled drug with high abuse potential) pain medication order was clarified with the physician when the order was unclear and incomplete. This failure had the potential for Resident 66 to receive the pain medication when it was not appropriate.

Inspectors wroteBased on interview and record review the facility failed to ensure 1 of 18 sampled resident's (88) end of life wishes were documented consistently. As a result, there was the potential for an error in the event of an emergency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Thoroughly investigate each of Resident 76's falls; 2. Consistently conduct fall IDT meetings after Resident 76 fell, and; 3. Develop and implement resident specific interventions in an effort to prevent further falls for Resident 76. As a result, Resident 76 sustained five falls over a four month period, and on the fifth fall, fractured a hip. Resident 76 suffered pain and became more dependent on staff for ADLs.

Inspectors wroteBased on interview and record review, the facility failed to ensure the pharmacy label on a medication pack matched the physician's order and MAR for 1 of 5 residents selected for unnecessary medication review (73). The facility also failed to ensure the physician's order for a medication indicated the total dosage to be given for 1 of 5 residents selected for unnecessary medication review (73). As a result, there was a potential for a medication error.