Niles Canyon Post Acute

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 2) had physician orders for hemoglobin A1C (a blood test that shows average level of blood glucose, also called blood sugar, over the past two to three months) monitoring every 6 months and or blood glucose capillary/fingerstick assessments (a rapid diagnostic method used to measure blood sugar found in the bloodstream, serving as the body's main source of energy for cells, tissues, and the brain) at least twice weekly. This failure resulted in Resident 2 having weakness and elevated blood glucose above 800 mg/dL. During record review of admission record, printed on 2/9/26, Resident 2 was admitted on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the physician failed to provide laboratory orders for routine monitoring of one of two sampled Residents' (Resident 2) who was ordered oral sitagliptin (an oral prescription-only medication used to lower blood sugar levels in adults with type 2 diabetes). This failure resulted in Resident 2 having weakness and elevated blood glucose above 800 mg/dL. During record review of admission record, printed on 2/9/26, Resident 2 was admitted on [DATE]. During record review of Resident 2's Minimum Data Set (MDS, an assessment used to guide care) dated 2/14/25, indicated Resident 2's Brief Interview for Mental Status (BIMS, an assessment used to assess mental status) score was 6 out of 15, indicated Resident 2 had severe cognitive impairment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff contacted the physician on two occasions regarding one of two sampled Residents' (Resident 2) elevated blood sugar levels, but physician did not review the recorded laboratory results, talk to nurse regarding Resident's status or order changes to Resident 2's treatment regimen. This failure resulted in Resident 2 having weakness, and elevated blood glucose above 800 mg/dL. During record review of admission record, printed on 2/9/26, Resident 2 was admitted on [DATE]. During record review of Resident 2's Minimum Data Set (MDS, an assessment used to guide care), dated 2/14/25, indicated Resident 2's Brief Interview for Mental Status (BIMS, an assessment used to assess mental status) score was 6 out of 15, indicated Resident 2 had severe cognitive impairment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to report hypotension (blood pressure less than 100/60 mm/Hg) to physician for one of two sampled residents (Resident 1). This failure resulted in Resident 1 being found hypotensive with a blood pressure of 76/44 and altered mental status (a sudden or gradual change in a person's baseline mental state, including confusion, decreased alertness, or disorientation). During record review of admission record, printed on 2/5/26, Resident 1 was admitted on [DATE]. During record review of Resident 1's Minimum Data Set (MDS, an assessment used to guide care) dated 12/4/25, indicated Resident 1's Brief Interview for Mental Status (BIMS, an assessment used to assess mental status) score was 15 out of 15, indicated Resident 1's cognition intact. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 1 held Basic Life Support (BLS; a professional credential verifying training in life-saving techniques for healthcare providers and public safety personnel) certification. This failure had the potential to result in residents' increased risk of adverse events during life-threatening, cardiac or respiratory emergencies. During a review of LVN 1's competency and skills folder, the BLS certification indicated, Renew by 07/2024. During a concurrent interview and record review on [DATE], at 2:16 p.m., the Director of Staff Development (DSD) stated LVN's need BLS and cardiopulmonary resuscitation (CPR; emergency life-saving procedure that is done when someone's breathing or heartbeat has stopped) training. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow doctor's orders to perform STAT (immediately or without delay) X-ray (imaging of inside of body) for over 10 hours for one of three sampled residents (Resident 1) after a fall at the facility. Resident 1 was later diagnosed with fracture (broken bone) of the Right Tibia (shin) and Fibula (calf bone) related to the fall. This failure resulted in Resident 1 to stay in pain/discomfort for over 10 hours and caused a delay in treatment. During a review of Resident 1's admission record printed on 1/8/26, the record indicated Resident 1 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect one of 15 sampled residents (Resident 164's) property from loss when their cell phone went missing. This failure had the potential to cause Resident 164 anxiety and stress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident food was stored in a safe and sanitary manner. This failure had the potential to cause infection and food borne illness to the residents that received food from the kitchen.

Inspectors wroteBased on observation, interview and record review the facility failed to follow food safety requirements when the following were noted: 1. Dietary staff did not perform hand hygiene after entering the kitchen. 2. Dishwasher did not reach 120ºF (degrees Fahrenheit) each time. 3. Multiple items were unlabeled and undated in the unit refrigerator. These failures had the potential for cross contamination. Findings 1. During an observation on 4/11/22 10:24 a.m., in the kitchen, Dietary Aide (DA) was observed donning an apron and gloves, without first performing proper hand hygiene. During an interview on 4/12/22, at 2:20 p.m., with Dietary Manager (DM), DM stated everyone should stop and wash their hands before doing anything in the kitchen. DM stated it's a risk for cross contamination. 2. [...]

Inspectors wroteBased on interview and record review the facility failed to accurately follow through the Preadmission Screening and Resident Review (PASARR) assessment process (a screening tool used to prevent individuals with mental illness (MI), intellectual disability (ID) or related conditions (RC) from being inappropriately placed in a Medicaid certified nursing facility (NF) for long-term care) for two of two sampled residents (Resident 1 and Resident 35) when following was noted: 1. Resident 1 did not receive PASSR level II evaluation. 2. Resident 35's PASSR level 1 assessmentwas not completed accurately to reflect the severely impaired cognitive status (mental status). This failure placed Resident 1 and Resident 35 at risk to not receive care and services appropriate to their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 254) received care when following was noted: 1. Resident 254 had long fingernails with black matter underneath on both hands. 2. Resident 254 did not receive shower/bed bath for four of five days within one week of readmission to the facility. This failure resulted in Resident 254 to feel helpless, placed him at risk for infections and hurting himself with long fingernails.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident received the volume of oxygen as ordered by the physician for two of two sampled residents (Resident 2 and Resident 37). This deficient practice resulted in Resident 2 and Resident 37 receiving more oxygen than required and can negatively impact both resident's the health and well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Activity Assistant (AA) performed hand hygiene in between residents while preparing and serving coffee to three of three sampled residents (Resident 52, 11 and 13). This failure placed Resident 52, 11 and 13 at risk for cross contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light (a device used by a patient to signal his or her needs for assistance) was within reached for four of 18 sampled residents (Resident 10, 33, 40 and 3). This deficient practice had the potential to result in the delay of care and services.

Inspectors wroteBased on interview and record review facility failed to provide a written summary of baseline care plan to one of three sampled residents (Resident 257). This failure resulted in Resident 257 not being aware of his plan of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the results of past State Inspections were readily accessible to the residents without having to ask the facility's staff for it. This failure placed the facility's residents at risk of not being informed of state inspections results for the past years.