Novato Healthcare Center

Inspectors wroteBased on interview and record review the facility failed to report an allegation of abuse for one resident (Resident 1) when Resident 1's Emergency Contact (EC, a trusted person designated to by notified by the facility of a resident's health status) notified the Social Service Director (SSD) of an allegation of misappropriation of Resident 1's property. This failure decreased the facility's potential to ensure the facility provided monitoring of Resident 1's psychosocial health and oversight of Resident 1's protection from further misappropriation of funds.

Inspectors wroteBased on interview and record review, the facility failed to investigate an allegation of misappropriation of resident property for one resident (Resident 1). This failure decreased the facility's potential to conduct a thorough investigation of an allegation of abuse and to protect Resident 1 from further misappropriation of funds.

Inspectors wroteBased on observation interviews and record review, the facility failed to ensure the required daily patient census and actual direct care service hours per patient day information was posted for 7/29/26 for a facility census of 178. The facility only displayed the estimated direct care service hours per patient day form dated, 7/30/26, and did not display actual direct care service hours provided to residents for the day prior on 7/29/26. The facility's failure to post the required daily patient census and actual direct care service hours per patient day information prevented residents, residents' representatives, staff, and members of the public from having access to current staffing information as required by law. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide or obtain physician ordered diagnostic services for one (1) of four (4) sampled residents (Resident 1), when a nephrology (the medical specialty focused on kidney care) consult had not been arranged within 30 days of the order date. This failure had the potential to place Resident 1 at risk for unmet clinical needs and a decline in condition. A review of Resident 1's Face Sheet (a facility demographic), dated 7/21/26, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including diabetes (a condition that happens when your blood sugar (glucose) is too high), neuromuscular dysfunction of bladder (a loss of bladder control caused by brain, spinal cord, or nerve damage), and history of urinary (bladder) tract infections. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to protect one of three resident's sampled for abuse (Resident 1), right to remain free from physical abuse when Certified Nursing Assistant 1 (CNA 1), ignored Resident 1's verbalizations of pain during transfer, requests for CNA 1 to stop cleaning Resident 1, and Resident 1's tears while CNA 1 continued to provide incontinence care. This failure caused Resident 1 to experience pain, feel scared, vulnerable, and treated like an object. A review of Resident 1's admission record indicated Resident 1 was admitted in 11/25 with diagnoses of displaced right femur fracture ( a break in her right thigh bone), collapsed vertebrae in thoracic region (occurs when the bone in your mid-back breaks and squashes into a wedge shape and often causes pain, height loss, and hunched posture) , and generalized muscle weakness. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Physical Therapy (PT-a healthcare specialty that uses movement, exercise, manual therapy, and patient education to reduce pain, restore physical function, and prevent injury) services were provided to seven of eleven sampled residents reviewed for PT services (Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9 ) when the facility had no current Director of Rehab (DOR), no current Physical Therapist (PT), no current Physical Therapy Assistants (PTA) to provide these services to residents with active physician orders. The affected residents did not receive their PT treatment as ordered. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an effective pest control program when flies were observed in the facility's residential areas. This failure had the potential to negatively impact the health and wellness of the residents through the inhalation or ingestion of the flies' droppings and other body parts.

Inspectors wroteBased on interview and record review, the physician and licensed nurses failed to ensure informed consent was provided to one resident (Resident 2) of four sampled residents when Resident 2's informed consent documentation was incomplete and indicated a lethal dose of medication to be administered. This failure resulted in Resident 2 being administered a psychotropic medication without verification of their right to be informed of the risks, benefits, and options of alternative treatment.

Inspectors wroteBased on interviews and record review, the licensed nurses to notify a resident's Responsible Party (RP, a person designated to make decisions regarding care when the resident is no longer able to) of a change of condition for one resident (Resident 1) of four sampled residents, when Resident 1's RP was not notified of Resident 1's fall on 6/16/26. This failure prevented Resident 1's RP of the knowledge of Resident 1's fall and the ability to make informed decisions regarding the fall incident (e.g. request for updates pertaining to the fall, request for x-rays if needed).

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident 2) of four sampled residents was free from unnecessary psychotropic medications (prescription drugs that alter brain chemistry, affecting mood, perception, thoughts, or behavior) when Resident 2 was prescribed lorazepam (a prescribed medication used to treat anxiety disorders) as needed (PRN) for 90 days. This failure decreased the facility's potential to safely administer psychotropic medications to residents.

Inspectors wroteBased on observation, interview, and record review, nurses failed to prevent an avoidable accident for one resident (Resident 1) of four sampled residents when staff/nursing supervision did not ensure Resident 1 used her walker while walking from her room to the nurse's station. This failure had the potential to result in an injury due to Resident 1 experiencing a staff-assisted fall on 6/16/26 in the memory care unit.

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of abuse was reported within the required timeframe for one of three sampled residents reviewed for abuse (Resident 1) when an allegation of abuse was reported to the Department outside of the two-hour timeframe. This failure to report promptly had the potential to delay regulatory oversight and impede timely protective interventions for Resident 1. A review of a facility document titled, Report of Suspected Dependent Adult/Elder Abuse (SOC 341), dated 5/25/26, indicated that Resident 1 was the victim of physical abuse that resulted in a fracture (break) to the second digit (index finger) on the left hand. The date and time of the incident was documented as 5/26/26 at 8:40 a.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to communicate postmortem care requirements for one of three sampled residents reviewed for postmortem care (Resident 2) when facility staff did not communicate Resident 2's postmortem care coordination efficiently and timely between internal facility departments and external entities. This failure resulted in a lack of clear direction and coordination with internal facility departments and external entities, which delayed Resident 2's necessary postmortem and cremation procedures. A review of Resident 2's admission record indicated he was admitted to the facility in [DATE] with medical diagnosis which included collapsed vertebra, thoracic region (when the bony block of the mid-back spine weakens and compresses into a wedge shape) and Alzheimer's (a disease characterized by a progressive decline in mental abilities). [...]

Inspectors wroteBased on interview and record review, the facility failed to protect one of five sampled residents (Resident 1) from physical and verbal abuse when Resident 2 struck Resident 1's left arm and yelled insults at him after an accident involving both residents on 5/01/26. This failure had the potential to result in Resident 1 experiencing post-incident pain, as well as possible feelings of fear about other residents residing in the facility. A review of Resident 1's Face Sheet, dated 5/05/26, indicated he was admitted to the facility on [DATE] with diagnoses including respiratory failure (when the lungs can't get enough oxygen into the blood, making breathing difficult), dementia (decline in memory, reasoning, and communication caused by progressive brain cell damage), and depression (serious mood disorder causing persistent sadness, loss of interest, and functional impairment). [...]

Inspectors wroteBased on interview and record review, the facility nurses failed to ensure one resident (Resident 1) of seven sampled residents received adequate assistance with her Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) when showers/ bed baths were not provided as scheduled. This failure decreased the facility's potential to ensure resident hygiene.

Inspectors wroteBased on interview and record review, the medical records staff failed to maintain complete, readily accessible, and systematically organized medical records for one resident (Resident 1) of seven sampled residents when medical records staff were unable to locate Resident 1's shower sheets. This failure decreased the facility's potential to ensure resident medical records were complete and accessible upon request. A review of Resident 1's admission record indicated she was admitted to the facility in October 2025 with the diagnoses of severe sepsis (a life-threatening blood infection). A review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 2/4/26, indicated Resident 1 had severe memory impairment. On 4/14/26 at 1:58 p.m., this surveyor requested to review Resident 1's shower sheets dated November 2025 to March 2026. [...]

Inspectors wroteBased on interview and records review, the facility failed to provide appropriate treatment and services to increase range of motion (the full distance and direction a joint, such as a knee, shoulder, or neck, can move, measured in flexibility and functionality) for one of three sampled residents (Resident 1), when Resident 1 was referred to the restorative nursing program (RNP, nursing led program in long-term care that helps residents maintain or improve their independence after formal therapy ends) but the facility failed to ensure an order had been obtained and RNP services were initiated. This failure had the potential to result in worsening of stiffening of joints of Resident 1's left hand and painful movements.

Inspectors wroteBased on interview and record review the facility failed to ensure two residents (Resident 2 and Resident 4) out of six sampled residents were free from physical and emotional abuse when:Resident 1 intentionally hit Resident 2 with his pillow. Resident 3 intentionally threw a full bottle of a nutritional supplement at Resident 4 which landed on Resident 4's face. These failures resulted in Resident 2 experiencing physical harm and caused Resident 4 to sustain a bruise to her left lower lip.

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate supervision for one resident (Resident 1) out of a sampled 6 residents when staff were unaware that Resident 1 eloped from the facility. This failure decreased the facility's potential to prevent serious injury, harm, or death to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to meet professional standards of quality and follow its own policies when Certified Nursing Assistant 1 (CNA 1) did not immediately report an incident of falls for one of three sampled residents (Resident 1). As a result, nursing staff did not promptly complete a change of condition assessment. This incident led to a two-day delay in diagnosing Resident 1's left arm fracture possibly caused by the fall, which resulted in an unwarranted postponement of appropriate treatment and pain management for Resident 1. During a review of Resident 1's admission Record (a facility demographic), dated 12/03/25, it indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Dementia (a condition that affects memory, thinking and behavior). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident 3) of four sampled residents was free from abuse when he was struck in the face by Resident 4. This failure resulted in Resident 3 sustaining a painful, sightly swollen, reddened area to his left eyebrow. A review of Resident 3's admission record indicated he was last admitted on [DATE] with the diagnoses of pressure ulcers and heart failure. A review of Resident 3's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 11/15/23, indicated Resident 3 had fully intact cognition (no issues with thinking or memory). A review of Resident 4's admission record indicated he was admitted on [DATE] with the diagnosis of Alzheimer's disease (a disease characterized by a progressive decline in mental abilities). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of verbal abuse was reported within the required timeframe for two residents (Resident 1 and Resident 2) of four sampled residents when the allegation was reported to the California Department of Public Health (the Department) the following day. This failure of timely reporting had the potential to cause a delayed response by enforcement agencies to ensure resident safety. A review of Resident 1's facility document titled, SBAR [Situation, Background, Assessment, and Recommendation- a tool used in healthcare settings to convey information quickly and clearly] Communication Form, dated 11/10/25 at 2:35 a.m. and signed by Licensed Nurse 1 (LN 1), indicated Resident 1 was involved in a verbal altercation with his roommate, Resident 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dietary staff were trained and had appropriate competencies and skills sets for a census of 162, when: 1. DA 1 was observed not wearing a hair net while working inside the kitchen,2. DA 2 did not follow the manufacturer's instruction for the use of red bucket test strips,3. The [NAME] could not verbalize the correct Cool-down Process of Hot food, and;4. The Dietary supervisor could not provide documentation of last quarter's cool down logs for both the Hot Food cool down process, and Ambient (Shelf stable food that can be safely stored in room temperature) cool down process. These failures reduced the facility's potential to ensure dietary staff were skilled and competent to provide dietary services to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pureed (cooked food that is blended to the consistency of a cream paste) food was prepared correctly for a census of 162, when temperature of a cold pureed fruit tested at 71.8 F and was warm to taste. This failure had a potential to result in food that does not meet resident nutritional needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety for a census of 162, when:1. Dietary Aid (DA) 1 was observed not wearing a hair net while inside the kitchen.2. Several various metal sheet pans and metal lids in clean and ready-to-use storage areas: a. Were stacked wet while stored away. b. Had food debris.3. There were bags of food items in the walk-in refrigerator and concerns related to frozen fish patties in the the walk-in freezer. a. The walk-in refrigerator floor was extremely wet b. One bag of carrot strips expired. c. One bag of open corn tortilla was not labeled with an open or use by date. d. One package of opened fish nuggets in a large 2-gallon size zipped bag had freezer burn.4. The oven had black residues at the bottom layer and was dirty.5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure five out of 40 sampled residents (Resident 58, Resident 135, Resident 42, Resident 116, Resident 124 and Resident 64) were treated with dignity when:Staff were feeding residents standing up and were not asking permission to wear clothes protector before mealtime during dining observationResident 64, who needed assistance with feeding was referred to as feeder. Licensed Nurse did not offer Resident 124 privacy during medication pass. These failures resulted in residents feeling rushed and undignified, caused Resident 64 to feel disrespected and had the potential to decrease his self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate documentation of the residents' wishes regarding their care was maintained for six of 40 sampled residents reviewed for Advance Directives (AD - a written instruction relating to the provision of health care when the individual is incapacitated) when: POLST (Physician's Order for Life-Sustaining Treatment) was not completed for Resident 10, and Advanced Directive were not completed or offered to Residents 13, 15, 18, 110, 122. These failures had the potential for Residents 10, 13, 15, 18, 110, 122 to not have their wishes and treatment preferences honored.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent when 22 medication errors were found out of 47 opportunities observed during a medication administration for three of 40 sampled residents (Resident 25 , Resident 124, Resident 46) when:1) Resident 25's prostate (male organ) medication was not given, and the wrong vitamin was administered;2) Resident 124's medications were crushed, medications were not given, and were not given according to physician orders; and3) Resident 46's blood pressure medication was not given, scheduled pain medication and morning medication were not given at scheduled time. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications were properly stored and labeled, for a census of 162 when:1. Medications were found at nurses station and at resident bedside unattended,2. Expired and discontinued medications were available for resident use,3. Loose pills were found in the drawers and the back of medication cart,4. Discontinued narcotics found in narcotic cart and Licensed Nurses (LN) are not counting during change of shift,5. Sticky residual found on outside of multiple bottles, and;6. Non medication items were found in medication cart. These deficient practices had the potential for residents to receive unsafe or reduced potency medications from being used past their expiration dates, improper storage, and diversion or misuse of medications from not being securely stored.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper infection control practices were implemented for a census of 162, when:Proper hand hygiene was not implemented during dining observation. Resident 150 has a suprapubic catheter (A suprapubic catheter is a medical device that helps drain urine from your bladder. It enters your body through a small incision in your abdomen) was not on Enhanced Barrier Precautions (EBP an infection control measures in nursing homes and similar settings to prevent the spread of multidrug-resistant organisms.) A shared blood pressure cuff was not cleaned and sanitized in between resident use. LN 4 did not properly wear N95 mask during medication pass. Multiple staff entered residents' rooms on isolation precautions without wearing the required face shields. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the needs were accommodated for two of 40 sampled residents (Resident 120 and Resident 140), when Resident 120's bed control remote (a handheld device that is connected by a cable to a bed and allows a person to adjust the position of a bed, elevate the head or feet) was not accessible to the resident and Resident 140's call light (a device used to contact staff for assistance) was not within the resident's reach. These failures resulted for Resident 120 and Resident 140 to experience frustration and anxiety when the residents were not able to reach bed control and a call for assistance.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of 40 sampled residents (Resident 97 and Resident 172) received necessary care and services to maintain good nutrition, grooming, and personal hygiene when:Resident 97 had long, thick toenails. Resident 172 was not provided assistance with eating and personal care. These failures reduced the facility's potential to provide Activities of Daily Living (ADL) care for Resident 97 and Resident 197, and had the potential to negatively affect their self-esteem, comfort, and personal hygiene.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 40 sampled residents (Resident 14) was offered activities that met their interests and preferences. This failure had the potential to affect the resident's physical, mental, and psychosocial well-being. During a review of Resident 14's admission Record (AR), the AR indicated Resident 14 was admitted on [DATE] with multiple diagnoses which included dementia (a progressive state of decline in mental abilities). During an observation on [DATE] at 11:25 a.m., 1:20 p.m., and 2:45 p.m. respectively, Resident 14 was in her room, sitting up on the bed with no activity. During an observation on [DATE] at 8:55 a.m., 11:22 a.m., and 1:23 p.m. respectively, Resident 14 was in her room, sitting up on the bed with no activity. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent one of forty sampled residents (Resident 157) from developing a facility acquired pressure injury (injury to the skin and underlying tissue due to prolonged pressure). This failure resulted in Resident 157 developing pressure injuries to right and left heels causing decreased mobility and increased risk for infection. A review of Resident 157's admission Record indicated Resident 157 was admitted to the facility June 2025 with multiple diagnoses including Alzheimer's disease (a progressive disease that destroys memory and other mental functions), obstructive sleep apnea (intermittent airflow blockage during sleep) and chronic kidney disease (loss of kidney function that filters waste from the body). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 40 sampled residents' (Resident 9) weight was not maintained when Registered Dietician's (RD) recommendation for therapeutic diet was not followed. This failure resulted in Resident 9's significant weight loss and had the potential to place the resident at risk for further weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate pain management was provided, consistent with professional standards of practice for one of 40 sampled residents (Resident 46), when the pain medication was not administered, administered later than the scheduled time, ongoing pain assessments every shift were not completed accurately, and the resident was not monitored for side-effects of pain medication. These failures resulted in Resident 46 experiencing uncontrolled pain and suffering, affected resident's simple movements causing frustration, and had the potential to increase his feeling of depression.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Licensed Nurse (LN) 17 had the specific skill sets and competencies necessary to care for residents' needs when LN 17 did not have a competency evaluation done before providing care to residents. This failure resulted in Resident 37 and Resident 46 receiving their medications late, which caused pain and discomfort. During a review of Resident 37's admission record, the admission record indicated, Resident 37 was admitted to the facility July 2023 with multiple diagnoses which included Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements). During a review of Resident 37's active orders dated 8/15/25, the orders indicated .Carbidopa -Levodopa (Combination medication used to treat the symptoms of Parkinson's disease. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of 40 sampled residents (Resident 64 and Resident 3) were free from unnecessary psychotropic medications (medications intended to control behavioral symptoms, including mind, emotions, and behavior) use, when:Resident 64 was prescribed Fluoxetine (an antidepressant medication) without specific manifested behavior of depression, and without monitoring for adverse effects (unwanted, uncomfortable, or dangerous effects). In addition, the facility failed to obtain an informed consent (voluntary agreement to accept treatment after receiving education regarding the risks and benefits, and alternatives ordered) before starting the antidepressant medication. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 resident in a census of 162 (Resident 46) was free from significant medication error when: 1) Licensed Nurse (LN) administered resident's pain medication late and not in accordance with the physician's orders and;2) LN did not administer blood pressure medicationThese failures decreased the facility's potential to ensure residents are able attain or maintain their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep a bed control remote (a handheld device that is connected by a cable to a bed and allows a person to adjust the position of a bed, elevate the head or feet) in a safe operating condition for one of 40 sampled residents (Resident 140), when the insulation (a protective barrier) around the electrical cord was broken exposing wires. This failure had the potential to result in serious risks to Resident 140's safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights were accessible for two of forty sampled residents (Resident 138, Resident 10) when:1. Resident 138's call light was shut in the nightstand drawer, and2. Resident 10's call light was on the floor behind the nightstand. These failures had the potential for Resident 138 and Resident 10 to have unmet care needs leading to increased risk for falls and injuries.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure one resident (Resident 1) of two sampled residents was free of a significant medication error when a double dose of insulin lispro (a fast-acting, man-made insulin (a hormone that regulates blood sugar allowing it to be used by our body as energy) used to treat diabetes) was administered by licensed nurses on the morning of 8/19/25. This failure resulted in Resident 1 having a hypoglycemic (when blood sugar level reaches a low level) episode in which she became unresponsive.

Inspectors wroteBased on interviews and record reviews, the facility failed to notify one resident (Resident 1) of two sampled residents about a significant medication error that occurred when licensed nurses administered a double-dose of insulin lispro (a fast-acting, man-made insulin (a hormone that regulates blood sugar allowing it to be used by our body as energy) used to treat diabetes) on the morning of 8/19/25 and caused Resident 1 to experience a potentially life-threatening hypoglycemic (a low blood sugar level that can cause harm; a level below 54 milligram per deciliter (mg/dl) is a cause for immediate action) episode, when her blood sugar level went down to 43 mg/dl. This failure denied Resident 1 her right to consent to subsequent treatments and to make informed decisions about her own plan of care.

Inspectors wroteBased on interviews and record reviews, the facility failed to assist one resident (Resident 2) of two sampled residents, to obtain dental care to be conducted in a timely manner, after the facility received a letter from a local oral surgery clinic which indicated Resident 2 had to be referred to a hospital to receive the procedure he needed. This failure decreased the facility's potential to ensure residents received the necessary care and increased Resident 1's potential to experience oral pain and discomfort which could negatively affect his health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to prevent one of six sampled residents (Resident 2) from being assaulted when Resident 1 hit Resident 2 on the back of her head. This failure resulted in Resident 2 feeling distressed and had the potential to result in Resident 2 experiencing feelings of fear and anxiety. A review of Resident 1's admission Record (AR), indicated the facility admitted Resident 1 on 6/19/25 with medical diagnoses which included end stage renal disease (a condition where the kidneys have permanently lost most of their function and can no longer adequately filter waste products and excess fluid from the blood) and vascular dementia (a type of cognitive decline caused by damage to the blood vessels in the brain). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of six sampled residents (Resident 3) received a federally required PASSR (Preadmission Screening and Resident Review - a federal requirement ensuring individuals with serious mental illness, intellectual disabilities, or related conditions are not inappropriately placed in Medicaid-certified nursing facilities and receive appropriate services) evaluation. This failure excluded Resident 3 from a complete mental health evaluation for appropriate facility placement, and non-receipt of available mental-health resources from the California Department of Developmental Services (DDS). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of abuse was reported within the required timeframe for two of two sampled residents (Resident 1 and Resident 2) when no documentation was received by the Department of Public Health (the Department) until four days after the alleged abuse occurred. This failure of timely reporting had the potential to cause a delayed response by enforcement agencies to ensure resident safety.

Inspectors wroteBased on interview and record review the facility failed to ensure one out of three sampled residents (Resident 1), was free from a significant medication error (an error in administering prescribed medication, which causes the resident discomfort or jeopardizes their health and safety), when the facility did not acquire nor administer Resident 1's antibiotic (a medicine that fights infection) per physician's orders. This failure could result in worsening of Resident 1's medical condition.

Inspectors wroteBased on interview and record review the facility failed to ensure the medical records were accurately documented for one out of three sampled residents (Resident 1), when Resident 1's medication administration record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) indicated, inaccurately, that Resident 1 was not administered a prescribed medication due to being in the hospital. This failure caused Resident 1's medical records to be inaccurate.

Inspectors wroteBased on interview and record review, the facility failed to implement and maintain their compliance and ethics program when the facility produced false evidence of nursing registry staff (licensed or certified nursing staff paid by a third party to work at a nursing facility) orientation. This failure contributed to the neglect of providing orientation and training to staff prior to working independently and placed the residents in the facility at risk of receiving unsafe care. On 5/19/25 the California Department of Public Health (CDPH) issued the facility a violation of federal regulations regarding the lack of effective training among nursing registry staff prior to independently providing services to residents. [...]

Inspectors wroteBased on interview, observation and record review, the facility failed to provide necessary services to maintain grooming and hygiene for two of nine sampled residents (Resident 1 and Resident 2). This failure resulted in both residents experiencing pain and anxiety and had the potential for skin breakdown and worsening of medical conditions.1. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure two of nine sampled residents (Resident 1 and Resident 2) received treatment when the facility did not perform necessary incontinent (having no or insufficient voluntary control over urination or defecation) care and hygiene. This failure had the resulted in both Residents experiencing pain and discomfort, and the potential for new development or worsening of medical conditions.1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary services for two of nine sampled residents (Resident 1 and Resident 2) when call lights were not operational, not adaptively placed for a disabled resident, and were not answered for a period of two hours. This failure resulted in both residents experiencing pain, discomfort, and anxiety secondary to delayed incontinence (involuntary leakage of urine or stool) care.1. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure accurate and complete resident medical records for four residents (Resident 1, Resident 2, Resident 3, and Resident 4) of four sampled residents when administration of medications during the evening shift of 6/18/25 was missing on their Electronic Medication Administration Record (EMAR). This failure decreased the facility's potential to ensure accurate documentation of resident care provided and increased the potential of medication errors.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure sufficient nursing staff for seven residents (Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, and Resident 8) of eight sampled residents when residents ' medications were not administered when scheduled. This failure decreased the facility ' s potential to safely meet the residents ' needs in a manner that promotes their physical well-being. Cross reference F760 and F940.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure six residents (Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, and Resident 7) of seven sampled residents, were free from significant medication errors when the following medications were not administered in accordance with the physician ' s order: 1. Resident 2 ' s insulin lispro (a rapid-acting medication used to treat Diabetes Mellitus (DM -a disorder characterized by difficulty in blood sugar control and poor wound healing)) and insulin glargine (a long acting, steady release medication used to treat DM) were administered late; 2. Resident 2 was administered the wrong dose of nutritional insulin (insulin lispro); 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure registry staff (nurses who work on a contracted as needed or temporary basis via contractual arrangement) were effectively trained prior to independently providing services to residents for a census of 174 residents. This failure decreased the facility ' s potential to provide person-centered care and reduce the potential of adverse events. Cross reference F725 and F760.

Inspectors wroteBased on observation, interview and record review, the facility failed to initiate and update person-centered care plans for two residents (Resident 4 and Resident 5) of eight sampled residents when Resident 4 and Resident 5 ' s care plans did not indicate preferences of their needs. This failure decreased the facility ' s potential to provide consistently communicated personalized care to residents. Cross reference F940.

Inspectors wroteBased on interviews and record reviews, the facility failed to establish and implement an appropriate abuse policy and procedure (P&P) when: 1. the facility's P&P titled Reporting Abuse was not revised to reflect current reporting guidelines, and 2. staff were not able to correctly state whom to report or the time frames to report abuse allegations. These failures could put all 174 residents of the facility at risk for abuse without timely interventions.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure five out of five sampled residents (Resident 7, 8, 9 10 and 11) baseline care plans (BCP, a document created within 48 hours of a resident's admission to a nursing home, outlining the initial care needed to ensure residents' safety and well-being, focusing on basic needs and resident-specific information) was completed within 48 hours of admission or that a copy of the BCP was given to those residents or the resident representatives. These failures could compromise the residents' care and could have resulted in health complications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure their smoking policy was implemented in a safe manner and was operationalized as per the set regulations regarding smoking, and protection for four out of four sampled smoking residents when: 1. Resident 3 was not wearing a smoking blanket/apron (protective covering, typically made from flame-retardant fabric, used to shield smokers from burns and protect their clothing from hot ashes and cigarettes) while smoking, 2. Resident 4 was not supervised by staff while smoking, 3. Resident 6 kept his own cigarettes, and 4. Residents were not following the facility's smoking schedule. These failures had the potential to endanger the health and safety of smoking residents.

Inspectors wroteBased on interviews and reviews, the facility failed to notify the physician of a significant change for one out of two sampled residents (Resident 12), when Resident 12's unintentional weight loss was not reported to the physician. This failure could result in missed opportunity to provide timely intervention.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure one resident out of two sampled residents (Resident 12) who was dependent on staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) received services to maintain grooming and personal hygiene when Resident 12 was not provided showers as scheduled. This failure could result in discomfort, skin impairment and body odor.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure the dignity of one out of three sampled residents (Resident 2) was protected when Licensed Nurse C (LN C) teasingly pinched Resident 2 on numerous occasions despite Resident 2 requesting multiple times for LN C to refrain from doing so. This failure resulted in Resident 2 feeling disrespected, frustrated, and her dignity was violated. Findings During a concurrent observation and interview on 5/1/25 at 11:12 a.m., Resident 2 stated LN C, a nurse who cared for her, had a habit of pinching her. Resident 2 stated LN C liked to pinch residents and added, LN C also pinched Resident 4. Resident 2 stated LN C would pinch her on her arms and added, she knew the difference between being pinched as necessary when being given an injection versus being pinched when LN C was teasing her. [...]

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to report the result of an investigation for an injury of unknown source (an injury where the source is not observed by anyone and the resident cannot explain how it occurred, and the injury is suspicious due to its location, extent, or the number of injuries) for one out of three sampled residents (Resident 1) when no report was received by the California Department of Public Health (the Department) within five working days of the incident. This failure of timely reporting had the potential to cause a delayed response by enforcement agencies to ensure resident safety.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to protect one resident (Resident 1) from physical abuse by Resident 2, when Resident 2 struck Resident 1 on the head with a coffee cup which shattered into small pieces. This failure resulted in Resident 1 being sent to the hospital Emergency Department (ED) for evaluation and treatment of a head injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure rehabilitative services were adequately provided for one resident (Resident 1) of three sampled residents when the rehabilitation staff (professionals who work together to help patients regain their functional abilities after illness, injury, or disability) did not carry out a physician order to evaluate Resident 1 for Physical Therapy (PT-A therapy that helps improve how the body performs physical movements), Occupational Therapy (OT- A therapy that encourages rehabilitation through the performance of activities required in daily life) and Speech Therapy (ST-A therapy that improves the ability to talk and swallow) services within 24 to 72 hours. As a result, these services were not provided to Resident 1 for several months. [...]

Inspectors wroteBased on interview and record, the facility failed to maintain the dignity of two of four sampled residents (Resident 3 and Resident 6) when Resident's 3 cheek was pinched without her consent and Resident 6 was continually not called by her preferred name pronunciation. This failure left Resident 3 and Resident 6 feeling angry and disrespected.

Inspectors wroteBased on interview and record review, the facility failed to ensure Licensed Nurses (LNs) administered medication to five residents (Resident 1, Resident 2, Resident 3, Resident 4, and Resident 5) of five sampled residents during a facility power outage which occurred on 12/14/25 to 12/15/25 when there was no documented evidence resident medications were administered. This failure resulted in residents who did not receive their medications and decreased the facility ' s potential to ensure residents received necessary medications during a power outage.

Inspectors wroteBased on interview and record review, the facility failed to ensure a contingency plan was in place and was included in the facility assessment for the administration of resident medication when the facility experienced a power outage on 12/14/24- 12/15/24. This failure resulted in five residents (Resident 1, Resident 2, Resident 3, Resident 4, and Resident 5) out of five sampled residents having no documented evidence their medications were administered and decreased the facility ' s potential to ensure residents received necessary care during a power outage. This was cross-referenced and cited at F658.

Inspectors wroteBased on interview, and record review the facility failed to ensure one resident (Resident 1), was free from verbal abuse when Physician A asked Resident 1, Aren't you a shit? This failure resulted in Resident 1 feeling upset and angry from being verbally abused.

Inspectors wroteBased on interview and record review the facility failed to report an allegation of verbal abuse in accordance with State law and established facility policies and procedures for one resident (Resident 1). This failure prevented the California Department of Public Health (CDPH, to be referred to the Department from here on) from investigating an allegation of abuse and continued to place Resident 1 and other residents at risk for abuse.

Inspectors wroteBased on interview, and record review, the facility failed to investigate an allegation of abuse following facility policy and procedures and State requirements for one resident (Resident 1). This failure decreased the facility's potential to prevent further alleged abuse from continuing and to take appropriate corrective action.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was discharged safely from the facility, when: 1. Resident 1, who was insulin-dependent (Dependent on injectable insulin, a hormone that helps blood sugar enter cells to be used for energy), was discharged from the facility without a glucometer (A small, portable machine that is used to measure how much glucose (a type of sugar) is in the blood), or information on purchasing a home-use glucometer. As a result, Resident 1 refused to administer his insulin for several days, since he could not check his blood sugar levels. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to become aware one of three sampled residents (Resident 1) had not received his early-morning Physician-prescribed insulin (An injected hormone that is essential for allowing the body to use sugar (glucose) for energy) most days of every month, for more than a year, until Resident 1 noticed this issue himself and reported it to Administration. As a result, Administration did not intervene until notified by Resident 1, which allowed daily significant medication administration errors to occur for Resident 1 for a period of one year, with a few exceptions. This finding had the potential to result in serious consequences for Resident 1, including uncontrolled blood glucose levels and death.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to implement the interventions to reduce the risk of elopement (leaving the facility without knowledge of the staff) for one out of one sampled resident (Resident 1), who left the facility, undetected, and was found by the local Police Department. This failure had the potential to result in serious injuries, including bruises, lacerations, head injury and broken bones.

Inspectors wroteBased on observation, interviews, and policy review, the facility failed to ensure concentration of sanitizer in the dish machine was at the correct concentration level. This deficient practice affected all residents who received food from the kitchen.

Inspectors wroteBased on interviews, record reviews, and facility policy review, the facility failed to ensure the resident's code status was accurately documented for 1 (Resident #169) of 34 sampled residents.

Inspectors wroteBased on observations, interviews, record reviews, and policy review, the facility failed to ensure privacy of protected health information for 2 (Resident #32 and Resident #141) of 34 sampled residents. Specifically, instructions for care were posted in sight of roommates, visitors, and others who might not be authorized to view this information.

Inspectors wroteBased on observation, interviews, record review, and policy review, the facility failed to develop and implement a care plan for 1 (Resident #141) of 1 sampled resident reviewed for communication. Specifically, a care plan for communication was not developed for Resident #141, who spoke a language other than English.

Inspectors wroteBased on observations, interviews, record review, and policy review, the facility failed to implement the use of alternative communication methods for 1 (Resident #141) of 1 sampled resident reviewed for communication. Specifically, the facility did not implement methods for communication with Resident #141 who spoke a language other than English.

Inspectors wroteBased on observations, interviews, record review, the facility failed to ensure staff set the low air loss mattresses (a mattress designed to distribute a resident's body weight over a broad surface and help prevent skin breakdown) according to the resident's weight for 2 (Resident #35 and Resident #77) of 3 sampled residents reviewed for pressure ulcer/injury.

Inspectors wroteBased on observation, interviews, record reviews, and facility policy review, the facility failed to provide supervision while smoking for 2 (Resident #125 and Resident #161) of 4 sample residents reviewed for accidents.

Inspectors wroteBased on interviews and record reviews, the facility ensure residents received timely treatment and care, when it failed to provide a timely dental referral for a denture (a small piece of plastic or similar material, with false teeth attached, that fits inside the mouth of someone who does not have their own teeth) evaluation for one out of two sampled residents (Resident 1). This failure led to Resident 1 feeling unhappy and frustrated at how the facility was treating him.

Inspectors wroteBased on interview and record review, the facility failed to ensure a deep tissue injury (DTI, an injury to the soft tissue under the skin due to pressure and is usually over boney prominence)for one resident (Resident 2), received care and treatment to promote healing and prevent worsening in accordance with professional standards of practice, when the facility failed to document wound care interventions in the medical record and care plan. This failure potentially worsened the resident ' s pressure ulcer and decline in the resident ' s quality of life.

Inspectors wroteBased on interviews and record reviews, the facility failed to identify risks, evaluate, and analyze risks and implement interventions to reduce risk when the facility did not provide physical supervision to prevent avoidable accident for one out of three sampled residents (Resident 1), while he was eating his sandwich alone in his room. This failure resulted to Resident 1 choking on his sandwich. Due to this choking incident, Resident 1 was sent to the hospital twice. Resident 1 was then diagnosed with multiple rib fracture which resulted to Resident 1 experiencing shortness of breath (SOB, the frightening sensation of being unable to breathe normally or feeling suffocated), desatting (a term used to mean that saturations (oxygen levels) are dropping) and complaining of 10 out of 10 pain level (the worst pain you have ever felt).

Inspectors wroteBased on observation, interview and record review, the facility did not ensure residents received care provided with dignity and respect, when residents were observed during meal service with towels wrapped around necks, meals were served on meal trays, Certified Nursing Assistants (CNA's) assisted dependent residents with meals while standing next to them, and in an environment that had chipped paint, rust and unsightly views of commodes. These failures had the potential to decrease residents' appetite, increase depression and residents' sense of loss and isolation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a comfortable, sanitary, and homelike environment, when: 1. The view in the main dining room consisted of two towers of stacked commodes, old furniture, broken equipment and black tarp that was ripped and unsecured, the walls, doors and chair rails had large amounts of chipped paint, and the floor contained stains and large amounts of black scraped marks. The dining room lacked pictures or photographs, a working clock or music, no table linens or table decor, and all resident meals were presented on plastic trays during meal service. 2. Multiple rooms (206, 207, 205, 202, 223, 217) and common areas did not look homelike, lacking pictures/photos, sufficient light, a television set or music. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff adhered to facility guidelines, when they were observed by several residents and staff using their personal cell phones in resident care areas. This failure had the potential to result in neglect of resident care and feelings of frustration for the residents involved.

Inspectors wroteBased on observation interview and record review, the facility failed to develop and implement comprehensive care plans, when: 1. Resident 125, who suffered a fracture on her left foot, did not have a nursing plan of care developed or implemented, to care for the fracture and prevent it from reoccurring; 2. Review of eight resident records in the Memory Care Unit indicated: Resident 132's activity care plan was dated four years after initial admission, five residents (Sampled Resident 56, 28, 13, 66, 133) did not have activity care plans, and eight residents (Sampled Residents 132, 133, 66, 13, 28, 56, 67 and 115) did not have quarterly activity care plan review / updates, and; 3. The facility did not ensure a nursing care plan for the prevention of constipation was created and implemented, for Resident 41. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide dental care to one of seven sampled residents (Resident 84) on several occasions. This failure had the potential to result in tooth decay and loss of teeth, affecting nutrition, comfort and dignity for Resident 84.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all residents had access to, and participated in, activities which reflected the preferences of each resident, when: 1. Individual and Group Activities for Residents of Unit Two were not observed or documented, Resident Activity Care Plans were not assessed, initiated and revised in a timely fashion, according to facility Policy and Procedure (P&P), for eight Sampled Residents (132, 133, 13, 66, 28, 56, 67, 115), and Activity staffing was insufficient to meet the needs of the residents, in Unit Two; 2. The facility did not provide activities to two dependent Residents (Residents 84 and Resident 165) based on their needs and interests, in Unit One, and; 3. The facility did not perform an activity assessment, and develop a care plan for Resident 378. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff provided appropriate respiratory care for two supplemental oxygen-dependent residents, when: 1. A Licensed Staff did not ensure an oxygen tank was changed before becoming empty, for a supplemental oxygen-dependent resident (Resident 24), and; 2. The facility did not follow physicians' orders in regards to oxygen administration, for one resident (Resident 127). These failures had the potential to result in serious harm and potential death to the residents involved.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure call lights were answered in a timely manner. This failure may result in residents' unmet needs and accidents.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure residents received services, activities and care required for them to achieve their highest practicable level of well-being, when the facility had 20 Certified Nursing Assistant (CNA) vacancies, 9 licensed nursing vacancies, 4 vacancies in the Activity Department, and 13 out of 30 housekeeping shifts went unfilled. These failures had the potential to contribute to decreased psychosocial well-being, rehabilitation services, activities, cognitive decline, and increased agitation, depression, and anxiety.

Inspectors wroteBased on observation, interview and record review, the facility failed to destroy controlled substance medications, according to facility policy. This failure resulted in the potential for unauthorized staff and residents to gain access to controlled substances.

Inspectors wroteBased on observation, interview and record review, the facility did not properly store and monitor residents' food in the units' refrigerators designated for the residents food from home. This was a problem for four of four refrigerators. This failure had the potential of residents having a food-borne illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure medical records were complete and accurate for Activities of Daily Living for two of four residents (Resident 84, and Resident 26). The records had missing documentation for daily consumption of meals and fluids, among other categories. This failure had the potential to result in inability for staff to respond to the status and needs of the residents, and lack of availability of information to facilitate communication among the Interdisciplinary Team.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement infection prevention and control practices, when: 1. Isolation and proper Personal Protective Equipment (PPE) use were not followed in the observation unit and in the lobby; 2. Staff did not practice hand hygiene during mealtime and did not offer residents hand hygiene during mealtime; and, 3. Two dietary aides wore cloth masks inside the kitchen. These failures may result in transmission of Covid-19 infection and other communicable diseases among residents and staff in the facility.

Inspectors wroteBased on interview and record review, the facility failed to notify the State Long Term Care Ombudsman of transfer to the hospital for one of three sampled residents (Resident 169). This failure may have resulted in Resident 169 not having an advocate for resident options and rights.

Inspectors wroteBased on observation, interview and record review, the facility failed to adequately assess two Residents, when: 1) Resident 118 did not have a hearing deficit physical reassessment; and, 2) Resident 149 did not receive ordered oxygen. These failures resulted in Resident 118 not being able to communicate her needs effectively with those around her and Resident 149 became short of breath when his 02 (oxygen) tank was found empty.

Inspectors wroteBased on observation, interview and record review, the facility staff failed to identify one Resident (Resident 160) prior to medication administration. This failure had the potential to harm one resident, who could have receive the wrong medication. During an observation and interview on 4/21/21 at 10 a.m., in Resident 160's room, Licensed Staff QQ did not check Resident 160's identity prior to medication administration. When queried, regarding the facility's policy on identifying a resident prior to medication administration, Licensed Staff QQ stated, We ask their name and birth date. Resident 160 did not to have a name band on his wrist. Licensed Staff QQ did not ask Resident 160 any identifying information prior to administering his medication. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of two residents (Resident 24), who required supervision while smoking, received the required supervision. This failure had the potential to result in a serious fire accident to Resident 24.

Inspectors wroteThe facility failed to ensure staff provided appropriate services for the care and maintenance of a suprapubic urinary catheter (A tube that drains urine from the bladder and is inserted into the bladder through a small hole in the lower abdomen) for one of two residents (Resident 9), when: 1. Resident 9's urinary catheter bag (The bag which collects the urine and is attached to the urinary catheter) was laying on the floor while the nursing assistant attended to Resident 9, and; 2. A physician's order to change the catheter every 30 days was not carried out for more than two months. These failures had the potential to result in major urinary tract infections for Resident 9.

Inspectors wroteBased on interview and record review, the facility failed to provide rehabilitative services to one of two residents (Resident 125), per physician's orders. This failure had the potential to result in decrease in range of motion and functional mobility, lack of independence, and decline in Activities of Daily Living.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement a performance improvement program in QAA (Quality Assurance Administration)/QAPI (Quality Assurance & Performance Improvement-A program to maintain safety and quality of nursing homes) to address the critical staffing shortages. This failure had the potential to result in further staffing shortages, causing inability of employed facility staff to meet the residents' needs, resulting in poor quality care.