Ocean Ridge Post Acute

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services to improve or maintain range of motion (ROM, full movement potential of a joint) for one of six sampled residents (Residents 61) with ROM concerns by failing to: 1. Ensure Resident 61's Restorative Nursing Aide (RNA, nursing aide program that help residents maintain any progress made after therapy intervention to maintain their function) program was appropriately modified to maintain and improve Resident 61's right arm ROM. 2. Ensure RNA 1 provided active assistive ROM (AAROM, movement at a given joint with a person's own effort and assistance from an external force or another person) exercises to Resident 61's both legs during an RNA session in accordance with physician's orders. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide medically related social services (professional interventions provided by social workers to help residents manage the emotional, social, and financial impacts of illness) for two of six sampled residents (Resident 19 and Resident 45) failing to:A. Ensure Resident 19 was seen by podiatrist (a medical specialist focused on diagnosing, treating, and rehabilitating conditions related to the foot, ankle, and lower leg) as requested. B. Ensure Resident 45 was seen by ophthalmologists (a medical specializing in comprehensive eye and vision care, including medical and surgical treatment) in three months as recommended. These failures had the potential to result in delay in the delivery of care and services.

Inspectors wroteBased on observation, interview, and record review the facility failed to:Ensure clean linen carts were accessed only by facility staff. Implement the facility's Policy and Procedure (P&P) titled Departmental (Environmental Services) - Laundry and Linen, which indicated all soiled linens and medical devices must be placed in the laundry area, in a covered laundry hamper which can contain the moisture. These failure had the potential to increase the risk of infection and cross-contamination (the transfer of bacteria, viruses, microorganisms, or other harmful substances from one surface to another through improper or unsanitary equipment, procedures, or products) among facility staff and residents.

Inspectors wroteBased on interview and record review, the facility failed to maintain staff documentation of screening, education, offering, and current Coronavirus Disease 2019 ([COVID-19] a new infectious viral disease that could cause respiratory illness) vaccination status for all licensed practitioners. These failures had the potential to increase the risk of transmission of COVID-19 and other respiratory infections to all residents.

Inspectors wroteBased on interview and record review, the facility failed to formulate Advance Directives ([AD]-written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) and Physician Orders for Life-Sustaining Treatment ([POLST]- a medical order that helps give people with serious illness more control over their care during a medical emergency) correctly in the medical records of two of 14 sampled residents (Resident 1 and Resident 13) by not:A. Ensuring the AD and the POLST were signed by a designated Responsible Party (RP) for Resident 1. B. Identifying a designated Resident Representative for Resident 13. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Case Manager (CM) reported one of six sampled resident's (Resident 51) multiple refusals for Orthopedic (specialty area in medicine referring to the management of the muscles, bones, and their connective structures) follow up appointments to the physician. This deficient practice resulted in a delay of Resident 51's care and had the potential for worsening of Resident 51's left shoulder and left ankle fractures, delayed healing, and a decline in mobility (ability to motion, range of motion (ROM, full movement potential of a joint), activities of daily living (ADL, basic activities such as eating, dressing, toileting), physical comfort and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of five sampled residents (Resident 10 and Resident 12) were free from unnecessary psychotropic (any drug that affects brain activity related to mental processes and behavior) medications by failing to:1. Ensure Resident 10 had an appropriate diagnosis before starting treatment with Xanax [(generic name - alprazolam) a prescription medication that slows down brain activity which helps reduce anxiety (constantly feeling worried and nervous)]. 2. [...]

Inspectors wroteBased on interview and record, the facility failed to ensure a Minimum Data Set ([MDS] - a resident assessment tool) assessment was completed accurately for three of 23 sampled residents (Resident 10, 12, and 19) by failing to:1. Ensure Resident 10 and Resident 12's mental health diagnoses was reflected in the resident assessment.2. Ensure Resident 19's dental health status was reflected in the resident assessment. This deficient practice resulted in incorrect data being transmitted to the Centers for Medicare and Medicaid Services (CMS) and had the potential to negatively affect the plan of care and delivery of care and services for Resident 10, 12, and 19.

Inspectors wroteBased on interview and record review, the facility failed to ensure four of 23 sampled residents (Residents 3, 10, 11, and 12) Preadmission Screening and Resident Review (PASARR) were reassessed appropriately by:Failing to ensure Resident 3 was reassessed for PASARR Level II upon readmissionFailing to ensure PASARR Level I was resubmitted when Resident 10 and Resident 12 had a new medication and diagnosis. Failing to ensure PASARR Level I was followed through with and reassess Resident 11's PASARR Level II upon admission. This deficient practice placed Residents 3, 10, 12 and 11 at risk of not receiving necessary care and services they need.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement an individualized care plan with measurable objectives, timeframes, and interventions for 2 of 3 Residents (Residents 51 and 19) by failing to:Develop a comprehensive care plan and conduct an Interdisciplinary Team (IDT, team of health care professionals that work together with the resident and or resident's representative to prioritize the resident 's needs and goals) meeting for Resident 51 who had a left shoulder and left ankle fracture (broken bone) and refused multiple times to follow up with orthopedic (branch of surgery concerned with conditions involving the muscles and bones) appointments per physicians recommendations. Develop and implement a comprehensive person-centered care plan for Resident 19's dental health status. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the comprehensive person-centered care plan was revised, updated, and reflected ophthalmologist (a medical professional specializing in comprehensive eye and vision care, including medical and surgical treatment) recommendations for one of seven sampled residents (Resident 45). This failure had the potential to result in Resident 45's vision worsening due to dry eyes and increased Intra Ocular Pressure (IOP- a measurement of the fluid pressure inside the eye).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for one of six sampled residents (Residents 51) by failing to follow up with an orthopedic (specialty area in medicine referring to the management of the muscles, bones, and their connective structures) consultation appointment for Resident 51's left humerus (upper arm bone) and left ankle fractures (broken bone) per consulting physician's recommendations. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 51) who had a left shoulder and a left ankle fracture (broken bone) was:1. Wearing a Controlled Ankle Motion boot (orthopedic device used to immobilize or protect the foot and ankle after an injury or surgery) during transfers (moving from one place to another) and walking and not weightbearing (putting pressure or force through an arm or leg) through the left arm per physician's orders2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Restorative Nursing Aide 1 (RNA 1) was competent to provide active assistive range of motion (AAROM, use of muscles surrounding the joint to perform the exercise but required some help from a person or equipment) exercises to one of six sampled resident's (Resident 61) both legs in accordance with physician orders. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete the performance evaluations (a way to measure how well you are doing a specific job or assignment) at least once every 12 months for Certified Nurse Assistants (CNA) 1, 2 and Restorative Nursing Aide (RNA - nursing aide program that help residents maintain any progress made after therapy intervention to maintain their function) 1. This failure had the potential to result in the inability to identify staff-specific clinical weaknesses, creating potential for nurse aids to perform tasks incorrectly and not meeting residents' needs

Inspectors wroteBased on observation, interview, and record review, the facility failed to clarify physician orders for two of six sampled residents (Residents 15's and 32's) by failing to:1. Clarify frequency (number of times) for administration of Resident 15's artificial tears eye drops.2. Clarify frequency and ensure that there was no risk of duplicate therapy for Resident 32's multiple acetaminophen (a medication used to treat fever and pain) orders. These deficient practices had the potential to cause medication errors, inadequate treatment or excess dosage for Residents 15 and 32, and placed Resident 32 at risk for acetaminophen toxicity and liver damage.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper labeling of medications in one of two inspected medication carts (Station 2 Medication Cart 2) according to manufacturer's specifications and ensure clean medication storage in one of one inspected medication room (Station 1 Medication Room) by failing to: 1. Ensure Resident 52's Lantus Solostar ([generic name - insulin glargine] a type of insulin [a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) pen in Station 2 Medication Cart 2 was labeled with an open date in accordance with manufacturer's specifications.2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to replace partial dentures and follow through with a dental visit as requested by the resident and Responsible Party (RP) for one of seven sampled residents (Resident 19). This failure had the potential to result in Resident 19 having discomfort and pain while chewing foods that could lead to unintended weight loss and lower self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of three sampled residents (Resident 46 and 91) understood the Arbitration Agreement ([AA]-a written contract where you agree to settle disputes out of court with a private, neutral person instead of judge or jury) prior to obtaining their signature. This failure had the potential to affect residents' rights, as residents may sign legally binding agreements without fully understating the terms, including the waiver of the right to pursue claims in a court of law.

Inspectors wroteBased on interview and record review, the facility failed to implement its abuse reporting and prevention policy and procedure (P&P) by failing to report unusual occurrences to officials which included the Long-Term Care Ombudsman, Law Enforcement, and the California Department of Public Health (CDPH) for one of five sampled residents (Resident 1), when Resident 1 sustained a displaced (bone snaps into two or more pieces and shifts out of alignment) fracture (break) through the left humeral neck (upper portion of the left arm bone just below the shoulder ball) injury of unknown origin. This failure had potential to result in a delay in an onsite inspection by the CDPH to ensure injuries from unknown origins were investigated and lead to a delay in preventing potential unknown injuries.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure strawberries, grapes, limes, and lettuce stored in the refrigerator maintained its quality and freshness 2. Ensure fruits and vegetables were maintained in a manner to conserve flavor, palatability, and appearance This deficient practice had the potential to impact 83 of 88 resident's nutritional status, quality of life and can lead to insufficient food intake.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in a sanitary manner to prevent growth of microorganisms (an organism that can be seen only through a highly magnifying lense) that could cause food borne illness (food poisoning: any illness resulting from the food spoilage of contaminated food, pathogenic bacteria, viruses, or parasites that contaminate food, as well as toxins) for 83 out of 88 total residents in the facility by failing to: 1. Ensure one onion and two bell peppers that were cut in half and placed in the refrigerator were labeled and dated 2. Ensure an unopened box of donuts (unknown count) stored in the refrigerator was labeled and dated 3. Ensure three bean burritos were labeled and dated 4. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure two out of two facility dumpsters were not overfilled and left with the lid open. This deficient practice had the potential to harbor and feed pest including rodents and flies.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one out of nine sampled residents (Resident 73) had access to her call light (a device that allows patients to request assistance from nursing staff). This deficient practice had the potential to not meet the needs for Resident 73 and placed her at risk for accidents.

Inspectors wroteBased on interview and record review, the facility failed to ensure five out of nine sampled residents (Residents 6, 24, 17, 28 and 79) had their level 1 Preadmission Screening and Resident Review (PASRR, is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) completed accurately. This deficient practice had the potential to delay care for Resident 6, Resident 24, Resident 17, Resident 28 and Resident 79 and had the potential they would not receive the proper level of care or services they required.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow physician's orders for enteral (a method of providing nutrition through a tube inserted into the gastrointestinal tract (GI tract) feeding for one of five sampled residents (Resident 42). This deficient practice had the potential for Resident 42 to experience continued weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide proper respiratory care for four of six residents ( Residents 69, 496, 492 and 53) by failing to: 1. Administer oxygen 2 liters (L- a unit of measure)/minutes(min) as ordered by the physician for Resident 69, 496 and 492. 2. Ensure adequate monitoring of oxygen saturation (amount of oxygen the body is processing) for one of three sampled residents (Resident 53) who was on oxygen for diagnosis of chronic respiratory failure (a long-term condition that makes it hard to breathe because the lungs can't exchange enough oxygen and carbon dioxide) and chronic obstructive pulmonary disease ([COPD], a chronic lung disease causing difficulty in breathing). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Manage residents' severe pain (7-10/10) appropriately for one of two sampled residents (Resident 79) by: a. Not notifying the physician of severe pain levels from 8/21/2024 to 1/23/2025 b. Not following the physician's ordered pain medication parameters c. Not accurately documenting pain in the minimum data set (MDS - a resident assessment tool) d. Not updating care plans to address continued pain e. Not consistently documenting pain location 2. Accurately assess one of nine sampled residents (Resident 32)'s pain per the physician's order. These failures resulted in a delay of obtaining the appropriate consults and providing a suitable pain management regimen and pain relief for Resident 79, and a potential for Resident 32 to exerience unnecessary pain.

Inspectors wroteBased on interview and record review, the facility failed to prevent a significant medication error for 1 out of three sampled residents (Resident 6) who was receiving medication for high blood pressure. This deficient practice had the potential for Resident 6 to experience hypotension (a condition where the blood pressure falls below normal levels and could cause dizziness or fainting) leading to the possibility of falls or accidents.

Inspectors wroteBased on observation, interview and record review the facility failed to follow appropriate infection control practices for three of three sampled residents by ; 1. Allowing Resident 22's indwelling urinary catheter (Foley-a small, flexible tube that is inserted into the bladder to drain urine when someone can't urinate on their own) drainage bag touched the floor. 2. Not replacing Resident 496's nasal cannula (NC-a small, flexible tube with two prongs that go inside your nostrils, used to deliver extra oxygen to someone who needs it) with new one after fell on the ground. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to report changes of condition (COC, major decline or improvement in a resident's status that will not resolve itself without intervention) for two of nine sampled residents (Resident 32 and Resident 58) with limited range of motion (ROM, full movement potential of a joint) concerns by failing to: 1. Report to Medical Doctor (MD) Resident 32's multiple, consecutive Restorative Nursing Aide (nursing aide program that help residents maintain any progress made after therapy intervention to maintain their function) refusals from February 2024 to August 2024 and from August 2024 to January 2025 in accordance with the facility's Policy and Procedure (P/P) tilted, Change in a Resident's Condition or Status. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately reflect two of three sampled resident's (Resident 21 and Resident 79) 1. Resident 21's medical diagnosis on the minimum data set (MDS, resident assessment tool). 2. For Resident 79 ensure pain frequency was accurately documented in the MDS. This deficient practice had the potential for Resident 21 to not receive person centered care related to her diagnosis of bipolar disorder (a mental health condition characterized by significant and persistent shifts in mood, energy, and activity levels) and Resident 79 to experience a delay of pain management care planning including obtaining the appropriate consults and providing a suitable pain management regimen and relief.

Inspectors wroteBased on interview and record review, the facility failed to create and implement a person-centered care plan for three of three sampled residents (Residents 73, 17 and 28). The facility failed to: a. Create a care plan for Resident 73 who experienced nausea and had an order for Zofran (medication used to prevent nausea and vomiting). b. Create a care plan for Resident 17 for taking controlled medication (temazepam, a sleeping aid to help with difficulty falling asleep or staying asleep) at night. c. Create a care plan for Resident 28 for self-care deficit and grooming pertaining to fingernails. These deficient practices had the potential not to provide resident specific care and monitoring.

Inspectors wroteBased on observation, interview, and record review, the facility failed to review and revise the comprehensive care plan for: 1.one of nine sampled residents (Resident 32) to address multiple, consecutive Restorative Nursing Aide (RNA, nursing program that uses restorative nursing aides to help residents maintain their function and joint mobility) refusals for Resident 32 who was identified as having left leg ROM limitations (ROM, full movement potential of a joint) and was at high risk for contracture development. 2.one of two sampled residents (Resident 79) to address severe pain that required increased use of as needed (PRN) pain medications from August 2024 to January 2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain good grooming, and personal hygiene for one of two sample residents (Residents 28). The resident was observed to have long fingernails with black material underneath. This deficient practice resulted in Resident 28's care needs not being met and had the potential to result in psychological harm and infection.

Inspectors wroteBased on interview and record review, the facility failed to follow the dietician's recommendations and obtain a physician's order for one of three sampled residents (Resident 32) to receive mid arm circumference measurements (a measurement of the muscle and fat in the upper arm. It's a simple and quick way to assess nutritional status and body composition) This deficient practice had the potential to delay care and delay identification of potential malnourishment (lack of proper nutrition, caused by not having enough to eat, not eating enough of the right things, or being unable to use the food that one does eat) for Resident 32.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment and services to improve and prevent a decline in range of motion (ROM, full movement potential of a joint) for one of nine sampled residents (Resident 32) who was identified as having left leg ROM limitations, was at high risk for contracture (loss of motion of a joint associated with stiffness and joint deformity) development, and repeatedly refused Restorative Nursing Aide (nursing aide program that help residents maintain any progress made after therapy intervention to maintain their function) services for left leg ROM exercises from February 2024 to January 2025. This deficient practice had the potential to cause Resident 32 to develop contractures and have a decline in ROM, physical functioning, and activities of daily living (ADL, basic activities such as eating, dressing, toileting).

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess one of one sampled resident (Resident 22) for indwelling urinary catheter (Foley-a thin, flexible tube inserted into the bladder to drain urine) removal when there was no documentation indicating that the resident's clinical condition required continued catheterization (inserting a thin, flexible tube called a catheter into a body cavity to drain fluid or examine an internal area). This failure had the potential to increase the risk of Foley catheter induced infections due to unnecessarily prolonged Foley Catheter use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure ClearLax ([generic name - polyethylene glycol] a medication used to treat constipation), Advair Diskus ([generic name: fluticasone-salmeterol] a medication delivered through a device in the form of inhalation powder, used to treat breathing problems due to asthma [a chronic lung disease causing inflammation and muscle tightness around airways] and chronic obstructive pulmonary disease [COPD - a chronic lung disease causing difficulty in breathing]) and Aspirin [a medication used to prevent heart attack (flow of blood and oxygen is blocked) and stroke (loss of blood flow to a part of the brain)] were administered in accordance with physician orders and manufacturer formulation specifications affecting three of four sampled residents during medication administration (Residents 35, 70 and 342). 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to act on two recommendations from the consultant pharmacist (a professional responsible for reviewing each resident's medication profile monthly to identify and report changes) from 12/11/2024 regarding lowering of the dose of Seroquel (generic name - quetiapine, a medication used to treat schizophrenia (a mental illness that is characterized by disturbances in thought) 150 milligram (mg - a unit of measurement for mass) once daily at bedtime and sertraline (a medication used to treat depression [sadness, low mood]) 50 mg once daily in one of five residents sampled for unnecessary medications (Resident 41). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate monitoring of side effect for one of two sample residents (Resident 53) who was receiving an anticoagulant (a medication used to prevent and treat blood clots [that can cause severe health issues] in the blood vessels and the heart) medication and were at high risk for bleeding from12/19/2024. This deficient practice had the potential to cause a delay in necessary care and services resulting in injury or death.

Inspectors wroteBased on interview and record review, the facility failed to obtain informed consent prior to administering a controlled medication (a drug or chemical that are regulated by the government for their manufacture, possession, and use) for one of three sampled residents (Resident 17) who was on temazepam (a medication used to treat certain types of sleep problem) for insomnia (a sleep disorder in which you have trouble falling asleep, staying asleep, or waking up too early). This deficient practice had the potential for Resident 17 to experience adverse (unwanted or dangerous medication side effects) effect of temazepam when receiving the medication without knowledge.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5% (percent) during medication pass for four of four sampled residents (Residents 35, 70, 342 and 36) by failing to administer ClearLax ([generic name - polyethylene glycol] a medication used to treat constipation), Advair Diskus ([generic name: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure Resident 81's lorazepam (a controlled substance [a medication with a high potential for abuse] used to treat anxiety [a medical condition described by feeling of fear or uneasiness]) 2 milligrams (mg - a unit of measurement for mass) per milliliters (mL - a unit of measurement for volume) concentrate was labeled with an open date in accordance with manufacturer's requirements in one of two inspected medication rooms (Station 1 Medication Room). 2. Ensure storage and/or labeling of two bottles of latanoprost ophthalmic solution (a medication in form of eye drops used to treat high pressure in the eyes), one Advair Diskus inhalation device ([generic name: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) services for one of nine sampled residents (Resident 32) who was identified as having left leg range of motion (ROM, full movement potential of a joint) limitations, was at high risk for contracture (loss of motion of a joint associated with stiffness and joint deformity) development, and repeatedly refused Restorative Nursing Aide (nursing aide program that help residents maintain any progress made after therapy intervention to maintain their function) services for left leg ROM exercises from February 2024 to January 2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of nine sampled residents (Resident 28) had complete and accurate physician's orders by failing to ensure Resident 28's splint (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) orders to both knees, the left elbow, and the left hand included the designated staff member to apply the splints and the splint wear time (length of time and frequency a person can tolerate wearing the splint for safety, comfort, and maximal benefits). This failure has the potential to result in an inaccurate depiction of care and services rendered for Resident 28.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement its Infection Prevention and Control Program for one of six residents (Resident 6) by failing to: 1. Ensure Certified Nursing Assistant (CNA) 1 put on an isolation gown when providing high-contact care for Resident 6 who was on enhanced barrier precautions ([EBP] infection control precautions in addition to the standard to prevent the spread of multidrug-resistant organisms). 2. Ensure proper perineal (the area of the skin located between the vagina and anus) care was provided to Resident 6. 3. Ensure CNA 1 properly discarded contaminated linens and incontinence (loss of bladder and/or bowel control) brief by opening the door with contaminated gloves to discard in the hallway. [...]

Inspectors wroteBased on interview, and record review the facility failed to implement its protocol for their antibiotic stewardship program (coordinated program that promotes the appropriate use of antibiotics by clinicians) for one out of three sampled residents (Resident 5) when the licensed nurses did not clarify a prophylaxis (used to prevent not treat an actual problem) order with the Nurse Practitioner (NP) 1 when resident 5 did not meet the McGeer (a check list to determine if a resident meets criteria for antibiotic treatment) criteria for Infection Surveillance (the systematic collection, analysis, and interpretation of data to monitor the health of a population and identify potential infections intended to prevent antibiotic resistance and organisms in the community). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of 92 residents (Resident 1), did not have a gun in his possession, in the facility. This failure had placed the other residents, staff and visitors ' safety in jeopardy and lives in danger, and could have resulted in severe injuries, hospitalization or death.

Inspectors wroteBased on interview, and record review, the facility failed to develop an individualized care plan for one of four sampled residents (Resident 1), who had an Out on Pass ([OOP] a temporary permission of a patient to leave the facility in a specified time) order and diagnosis of suicidal ideations (thinking about or feel preoccupied with the idea of death and suicide [ending own life]). This deficient practice resulted in staff not knowing what interventions should have been followed and implemented when Resident 1 returned to the facility from OOP. This deficient practice had potentially affected in maintaining Resident 1 ' s highest practicable physical, medical, and psychosocial well-being, that might have contributed to Resident 1 ' s death.

Inspectors wroteBased on interview and record review, the facility failed to provide supervision and an environment free of accident hazards, to one of four sampled residents (Resident 1), when: 1). Resident 1 who was admitted to the facility on [DATE], and with diagnoses of opioid dependence (a chronic disease that occur when someone regularly use opioids [strong pain killers] and develops a strong drive to continue using them, even when it causes harm), and suicidal ideations (thinking about or planning suicidal), with Out On Pass ([OOP] a temporary permission of a patient to leave the facility) order on [DATE] without supervision, was not assessed when returning to the facility. 2). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure, one of four sampled residents (Resident 1), had no medications at the bedside. This failure had potentially caused the resident drug overdose that resulted in in death.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for one of three sampled residents (Resident 1) by failing to: A. Ensure Certified Nurse Assistant (CNA) 1 answered Resident 1s' call light in a timely manner. B. Ensure CNA 2 answered Resident 1's call light and provided hygiene care with adult briefs change in a timely manner. This failure has potential to result in Resident 1 feeling ignored and like he did not matter, and placedResident 1 at risk for skin breakdown due to sitting in soiled adult briesf for a long period of time.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of three sampled resident's (Resident 2) medical record was complete and accurate when a. the facility failed to document an assessment after an allegation of suspected drug use was made regarding Resident 2. b. the facility failed to enter the correct date and time of a weekly assessment completed for Resident 2. This deficient practice resulted in an inaccurate depiction of Resident 2's care and health status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: a. Ensure open food items in the freezer and refrigerator are labeled and dated. b. Ensure the dishwashing machine was running at the proper temperature. These failures had the potential to place residents at risk for food-borne illnesses (any illness resulting from ingestion of food contaminated with bacteria, viruses or parasites).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure their Dishwashing Machine was maintained to wash dishes and utensils at 120 degrees Fahrenheit (F, a unit of measure of temperature) as recommended by the manufacturer. This failure had the potential to place residents of the facility at risk for spread of infection and food-borne illnesses (any illness resulting from ingestion of food contaminated with bacteria, viruses or parasites) due to dishes and utensils not being sanitized by water at 120 degrees F.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care in a manner that maintained or enhanced a resident's dignity and respect in full recognition of their individuality by failing to place the call light within reach for one of two sampled residents (Resident 40), and failure of staff to self identiy with a name tag when caring for one of two sampled residents (Resident 24). This failure resulted in Resident 40 feeling helpless and caused a loss of dignity, and self-esteem due to not being able to get help when he needed it and Resident 24 not knowing who was taking care of him.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, sanitary, and homelike environment for 89 of 89 sampled residents by failing to ensure ceilings in the dining area, Rehabilitation Department (health care services that help, get back or improve skills and functioning for daily living of residents that have been lost or impaired due to illness) and resident 's doorway was not leaking with water from the rain. This failure had a potential to place residents at risk for accidents and create poor quality of life related to possible exposure to mold (fungal growth that forms and spreads on various kinds of damp places and could make people sick) due to water damage.

Inspectors wroteBased on interview and record review, the facility failed to inform residents on how to file a grievance (an expression of dissatisfaction or complaint regarding any aspect of their care) for three of seven sampled residents (Resident 13, Resident 35 and Resident 188). This failure had the potential to make residents feel unimportant, helpless and unaware of their rights as a resident in the facility.

Inspectors wroteBased on interview and record review, the facility failed to protect one of two sampled residents (Resident 35) from inappropriate verbal language from another resident (Resident 27) in the dining area. 1. By failing to separate and intervene when Resident 35 and Resident 27 were yelling at each other. This failure resulted into Resident 35 feeling unsafe when Resident 27 is around her and had the potential to negatively impact Resident 35's security and emotional well-being.

Inspectors wroteBased on observation, interview, and record review, the facility Staff failed to meet professional standards of quality for one of three sampled residents (Resident 41) by not giving the full dosage of Resident 41's ipratropium-albuterol inhalation solution (medication used to help control symptoms of difficulty breathing). This deficient practice had the potential to cause Resident 41 to have complications of shortness of breath due to an insufficient dosage of medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatments and services to four of six sampled residents (Residents 69, 16, 53, and 59) to prevent and/or limit a decline in joint (where two bones meet) range of motion (ROM, full movement potential of a joint) and mobility (ability to move). a. For Resident 69, the facility failed to provide ROM services to maintain or prevent a decline of Resident 69's both arms and both legs. b. For Resident 16, the facility failed to provide Restorative Nursing Aide (RNA, nursing aide program that helps residents maintain their function and mobility) ROM exercises to both arms, five times a week as ordered. c. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure opened and used insulin glargine (a long-acting medication used to control blood sugar) with no open date and expiration date for one of three inspected medication carts (Cart 2) 2. Ensure two unopened insulin lispro pens (a medication used to control blood sugar) were stored in the refrigerator per the manufacturer's requirements affecting two of three inspected medication carts (Cart2 and Cart 1). This failure had the potential to result in Residents who are receiving medication that had become ineffective or toxic due to improper storage or labeling, possibly leading to health complications resulting in hospitalization or death by failing to store and label medications per the manufacturers' requirements.

Inspectors wroteBased on observation, interview and record review the facility failed to observe infection control measures for four (Resident 4, Resident 24, Resident 25, and Resident 41) of 19 sampled residents by failing to: 1. Clean the medication cart between Residents after passing medications. 2. Ensure proper hand hygiene was performed during mealtime for Resident 4. These deficient practices resulted in contamination of the resident's care equipment and placed the residents at risk for infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of six sampled residents (Resident 69) participated in the development and implementation of his care plan by failing to: a. Ensure Resident 69 was informed of the changes in the care plan when skilled Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) and Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) were discontinued. b. Ensure Resident 69 participated in the care planning process when skilled PT and OT services were discontinued. These deficient practices had the potential to violate Resident 69's right to be an active participant in his care.

Inspectors wroteBased on interview and record review, the facility failed to follow through and accurately assess with the Preadmission Screening and Resident Review (PASRR- a comprehensive evaluation that ensures people who have been diagnosed with serious mental illness, intellectual, and/or developmental disabilities are able to live in the most independent settings while receiving the required and recommended care and interventions to improve their quality of life) level I and level II (if indicated) evaluation for two of three sampled residents (Resident 40 and 37) to determine the facility's ability to provide the special need of the residents. This deficient practice placed Resident 40 and Resident 37 at risk of not receiving necessary care and services they need.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement an individualized care plan with measurable objectives, timeframes, and interventions to improve, prevent and/or limit a decline in joint (where two bones meet) range of motion (ROM, full movement potential of a joint) for one of six sampled residents (Resident 69) who was at high risk for contracture (loss of motion of a joint associated with stiffness and deformity) development of both arms and both legs. This deficient practice had the potential to negatively affect the delivery of necessary care and services for Resident 69 and lead to contracture development and a decline in overall physical functioning such as the ability to move, eat and dress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 37) received continuous positive airway pressure ([CPAP] is a machine that uses mild air pressure to keep breathing airways open while sleeping) during the night as ordered by the physician. This failure had the potential to place Resident 37 at risk for obstructive sleep apnea(muscles that support the soft tissues in the throat, such as the tongue and soft palate temporarily relax causing the airway to close or narrow and momentarily stops the breathing )and respiratory arrest( absence of breathing).

Inspectors wroteBased on observation, interview, and record review the facility failed to provide effective pain management for one of six sampled residents (Resident 138) by failing to: 1. Implement their policy titled Pain Assessment and management to ensure Resident 138's pain level was assessed and reassessed in a timely manner. 2. Ensure appropriate pain medication was provided according to pain assessment. This failure placed Resident 138 at risk for unrelieved pain and delay of necessary treatment and care.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide one of 13 sampled residents (Resident 76) pureed diet (a diet that was designed for people who have trouble chewing and swallowing with no lumps and has a texture like pudding) as ordered by the physician. This failure had the potential to result in an accident such as chocking and aspirating (food, liquid, or other material enters a person's airway and eventually the lungs by accident).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the proper assistance to ensure one of six sampled residents (Resident 59) had clean adaptive eating utensils (AE, eating equipment such as forks, knives, and spoons that are modified to increase independence with eating) for her use during meals. This deficient practice had the potential to cause Resident 59 to have decreased independence with self-feeding, weight loss, increased frustration and stress, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide therapy services, including Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) and Occupational Therapy (OT, profession aimed to increase or maintain a person's capability of participating in everyday life activities) for one of six sampled residents (Resident 69) who had range of motion (ROM, full movement potential of a joint [where two bones meet]) and mobility (ability to move) concerns. For Resident 69, the facility failed to provide rehabilitative services when the facility discontinued Resident 69's PT and OT services despite Resident 69 making functional gains in therapy and demonstrating skilled therapy (services that require specialized training and experience of a licensed therapist or therapy assistant) needs. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure one of four sampled residents (Resident 1) grievance (complaints regarding treatment, care, management of funds, lost clothing, or violation of rights) involving concerns with facility noise level was investigated, a resolution was completed within five working days upon receipt of the grievance, and ensure the original copy of the grievance was not misplaced, per the facility ' s policy and procedure (P/P) titled, Grievance Procedure. This deficient practice resulted in Resident 1 status of the grievance being unbeknownst to her and resulted in Resident 1 having feelings of frustration, unimportance, and feelings of concern that the grievance filed didn ' t matter to the facility because the issues she had addressed on the grievance were still occurring.

Inspectors wroteBased on interview and record review, the facility failed to obtain and document vital signs ([v/s] clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions) and assess/monitor for signs and symptoms (s/s) of COVID-19 (a potentially severe respiratory illness caused by a coronavirus and characterized by fever, coughing, and shortness of breath) to include resident ' s temperature, respiratory rate, heart rate, oxygen saturation level, chills, headache, change In mental status, shortness of breath, cough, sore throat, runny nose, chest pain, diarrhea, nausea, vomiting, loss of taste/smell, fatigue, muscle ache and fever, for two of two sampled residents (Residents 1 and 2), by failing to: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician was for one of two sampled residents (Resident 3) was informed when red marks, abrasions and bruises were found on Resident 3 ' s face and chest. This deficient practice resulted in Resident 3 ' s physician being unaware of the injuries to Resident 3 ' s face and chest and a delay in treatment to Resident 3 ' s face and chest.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse for one of two residents (Resident 3), when Resident 3 was found with red marks and abrasions to his face, forehead, nose, ears, lip, and eyebrows on 12/10/2023. This deficient practice resulted in a delay in the California Department of Public Health ' s (CDPH) investigation and had the potential to result in further abuse to go unreported. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Certified Nursing Assistant 5 (CNA 5) from the registry company (an agency that offers health care related contracts for nurses, home health aides, certified nursing assistants, homemakers, and companions in a patient's home and as temporary staff to health care facilities) received abuse training prior to working at the facility. This deficient practice resulted in the facility being unaware of registry staff ' s knowledge of abuse regulations and placed residents at risk for abuse, neglect, and exploitation. Findings During a review of an email dated 12/10/2023 and timed at 9:30 p.m. between the Director of Staff Development (DSD) and the Registry company, the email indicated the DSD could not find proof of abuse training in the registry company ' s uploaded documents for CNA 5. During an interview on 12/14/2023 at 12: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain appropriate infection control practices by: 1. Failing to ensure a staff member wear a well-fitting mask in the presence of a resident (Resident 2) who was exposed to a roommate who developed Covid-19 (coronavirus disease, a severe respiratory illness caused by a virus and spread from person to the person through respiratory droplets) in the dining area. 2. Failing to ensure Resident 2 was wearing well-fitting mask while in the dining area. These failures had the potential to result in spread of infection among the residents and staff members.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of four sampled residents (Resident 4), who was aphonic (unable to speak) and understood only Spanish, was provided a communication tool he can read and understand. This deficient practice had a potential for delay of appropriate care and services to Resident 4.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of four sampled resident's (Resident 4) call light was acknowledged and answered in a timely manner. This deficient practice has a potential for delayed delivery of appropriate care and services to Resident 4.

Inspectors wroteBased on interview and record review, the facility failed to ensure Baclofen (medication used to treat pain and muscle spasms/muscle cramps) was administered per physician orders and documented accurately for one of one residents (Resident 4). These deficient practices had the potential for medication overdose or underdosage which can cause increased side effects (unpleasant effect), muscle spasms and pain for Resident 4.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the back patio outdoor flooring was not uneven with holes for two out of two sampled residents (Resident 1 and 2). This deficient practice made it unsafe, difficult, and uncomfortable for residents in wheelchairs to access the patio and placed residents at risk for injury and falls.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled residents (Resident 1), who was frequently incontinent (inability to control) of bowel and was at high risk for pressure ulcer (an injury that breaks down the skin and underlying tissue) development, received or was offered toileting assistance at least every two hours and as needed. These failures resulted in Resident 1 experiencing feelings of embarrassment and anger in having to wait to be cleaned while sitting in feces.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one out of three direct care staff (Restorative Nurse Assistant [RNA 1]) donned (put on) an N- 95 mask (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) and eye protection while taking care of Resident 6, a corona virus disease ([Covid 19] a highly contagious infectious disease) positive resident, while in the resident's isolation room (room for separation of resident from other people while they receive medical care). This deficient practice had the potential to transmit Covid-19 to other residents and staff in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the provision of accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident by: 1. Failing to ensure the licensed nurses checked if the Cholestyramine (medication used to treat diarrhea [the passage of three or more loose or liquid stools per day]) for one of three residents (Resident 1) was available by checking the medication rooms and medication cart thoroughly. 2. Failing to administer the Cholestyramine 4 milligrams ([mg] unit of measurement)/milliliter ([mL] one thousandth of a liter) twice a day (BID) as prescribed by the physician for one of three sampled residents (Resident 1). This deficient practice resulted in Resident 1 not receiving her prescribed medication, placing her at risk of uncontrolled diarrhea. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to treat one of three sampled residents (Resident 2) with dignity and respect by failing to cover Resident 2 ' s unclothed perineum (area between the thighs which contains the genitals [vaginal opening or scrotum]) and buttocks while transferring the resident from the shower gurney (used to transport an immobile person to and from a bathing area) to Resident 2 ' s bed in the hallway. This deficient practice resulted in Resident 2 ' s perineal and buttocks being visible to staff, visitors, and other residents in the facility and had the potential to cause embarrassment, unworthiness, and psychosocial harm to Resident 2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Certified Nurse Assistant 1 (CNA 1) used a battery-operated patient lift (helps caregivers lift and transfer patients from one place to another) with another staff when transferring one of three sampled residents (Resident 2) from a shower gurney (used to transport an immobile person to and from a bathing area) to the bed. This deficient practice had the potential to result in an accident that can cause physical injury and harm to Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to provide documentation on the status for one of two sampled residents (Resident 1) before Resident 1 left the facility to go to an outside medical appointment and on return to the facility. This deficient practice resulted in Resident 1 pre and post status being unknown and had the potential for unrecognized changes in condition (COC) and non-continuity of care from medical staff.