Pacific Care Nursing Center

Inspectors wroteBased on interview and record review, the facility failed to ensure residents, at high risk for falls and injuries, received fall prevention interventions for one of three sampled residents (Resident 1). The facility failed to:1. Ensure Certified Nursing Assistant (CNA) 1 was aware of Resident 1's high fall-risk status.2. Ensure Resident 1's physician (MD) orders dated 2/12/2026 for fall prevention devices including floor mats (cushioned pads placed on the floor besides a resident's bed to decrease the impact of a fall) and bilateral bolsters (firm, padded foam cushions placed along the sides of a bed to act as soft, safe bumpers to prevent residents from rolling out of bed) were not discontinued on 2/13/2026, despite Resident 1 continuing to be assessed as high risk for falls and injuries.3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was not moved following a fall from the bed to the floor. The facility failed to:1. Ensure Certified Nursing Assistant (CNA) 1 and facility staff safely cared for Resident 1 by leaving him in place on the floor until paramedics arrived, as required for suspected head, neck, or spinal injuries after a fall on 5/2/2026.2. Ensure staff followed Resident 1's Care Plan titled At Risk for Fractures initiated 2/12/2026, which indicated, the facility must minimize the risk for fracture (broken bone) by assessing for possible risks sustain a fracture such as unsafe transfers.3. Ensure staff followed the facility's policy and procedure (P&P) titled Falls by a Resident, revised 7/2017, which directed staff not to move a resident after a fall until assessed by a licensed nurse. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the nursing staff had specific competencies and skills sets necessary to care for one of three sampled residents (Resident 1) needs by failing to:1. Ensure Certified Nurse Assistant (CNA) 1 did not move Resident 1 onto his left side after he fell from the bed to the floor.2. Ensure the nursing staff did not move Resident 1 from the floor back to the bed after Resident 1 fell and sustained a forehead laceration (a rough, tear or cut in the skin and underlying soft tissues, usually caused by blunt trauma [forceful impact]) and bruising his face.3. Ensure CNA 1 was aware of Resident 1's high fall risk status. This failure had the potential to place Resident 1 and other residents at risk for increased harm of unknown internal injuries from the fall.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), who had an existing pressure ulcer ([PU] localized damage to the skin and/or underlying tissue usually over a bony prominence) was turned and repositioned at least every two hours. This deficient practice resulted in Resident 2 being left in the same position on his left side for over four hours and had the potential for new PUs to develop and a delay in healing for Resident 1's existing PU.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement infection control measures for one of two sampled residents (Resident 2) by failing to:1. Ensure Certified Nursing Assistant (CNA)1 and Registered Nurse (RN)1 wore required personal protective equipment (PPE- clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) before entering Resident 2's room who was on contact isolation ( a set of safety steps used in the facility to stop the spread of germs that are passed by touching a patient or contaminated items in the resident's room). This failure had the potential to spread and transmit infections to all residents, staff and visitors.

Inspectors wroteBased on interview and record review the facility failed to ensure grievances (a perceived wrong or other cause for complaint or protest, especially unfair treatment) made during resident Council (an independent organized group of residents of that facility who meet to discuss concerns, develop suggestions on improving services, and plan social activities) meetings regarding slow call-light response from the 11 p.m. to 7 a.m., shift was promptly addressed and did not negatively affect four of four sampled residents (Resident 1, Resident 2, Resident 3, and Resident 4). This deficient practice had the potential to cause delays in care and as a result of the deficient practice Resident 1, Resident 2, Resident 3, and Resident 4 continued to experience slow response times when pressing the call light during the 11 p.m. to 7 a.m. shift. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident with a gastrostomy tube (GT-a tube that is passed through the abdominal wall to the stomach used to provide nutrition) site was not leaking from January 2025 to present for one out of eight residents (Resident 8). This deficient practice resulted in continuous leakage of tube feeding formula around Resident 8's stoma (surgically created opening on the abdomen that allows waste to exit the body) site with Resident 8 being transferred to the General Acute Care Hospital (GACH) and had the potential to cause skin breakdown around the site, lead to malnutrition, infection and Resident 8 not receiving the volume of tube feeding formula ordered by the physician.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident's pain was managed for one of two sampled residents (Resident 100); who had multiple pressure ulcers (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence), a healing right arm fracture, and right knee surgical site. Specifically, the facility failed to:1. Ensure that staff followed Resident 100's care plan titled, Alteration in Comfort - Pain which indicates to provide nursing measures that will provide comfort and lessen intensity of pain by repositioning, offering pain medication, and reassessing effectiveness of pain medication after 30 minutes.2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain accurate documentation on accountability record or controlled medication count sheet/controlled drug record ([CDR] - a document indicating perpetual inventory and administration of controlled substances affecting three residents (Residents 66, 76 and 90) in one of three inspected medication carts (Middle Medication Cart Skilled Nursing Facility [SNF] side).1. Resident 76's Pregabalin (a controlled medication [medications that the use and possession of are controlled by the federal government] used to treat fibromyalgia [pain in muscles and soft tissues] related pain, neuropathic (nerve related) pain and a subset of seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]).2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to:1. Store, label and/or discard Resident 41 or 42's Epogen ([generic name - epoetin alfa] a medication used to treat anemia [low red blood cell count]) and Resident 100's Retacrit ([generic name - epoetin alfa-epbx] a medication used to treat anemia) in accordance with manufacturer's specifications and facility's policy and procedure (P&P) titled, Vials and Ampules of Injectable Medications, dated 4/2008, affecting one of one inspected medication room (Medication Room).2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control precautions for three of four sampled residents (Resident 100, Resident 8 and Resident 40) when:1a. Certified Nursing Assistant (CNA) 2 picked up a pillow and bed linen from the floor and placed it on Resident 100's lower extremities (lower legs, feet).1b. CNA 2 did not follow the standard of practice of wiping front to back when cleaning Resident 100's rectum. 1c. CNA 2 did not perform hand hygiene after providing perineal ( the area of the body between the anus and the external genitalia) care on Resident 100.1d. CNA 2 failed to doff (remove) personal protective equipment (PPE) before leaving Resident 100's room.2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 75) was free of unnecessary physical restraints (any object or device that an individual cannot remove easily which restricts freedom of movement) by failing to:1. Ensure physician order for the use of restraint was obtained before initiating a physical restraint in the form of a sock which covered the right arm and right hand with tape wrapping the fingers.2. Ensure an assessment and monitoring of the use of physical restraint for the right arm and hand were implemented and documented. This failure had the potential to place Resident 75 at risk for unnecessary prolonged use of restraints, and could lead to decline in physical functioning, impaired blood circulation, and skin injuries.

Inspectors wroteBased on observation, interview, and record review, Licensed Vocational Nurse (LVN) 4 failed to ensure Resident 8's Acidophilus ([generic name - lactobacillus] a probiotic supplement used to improve gut health) was completely dissolved before being administered via gastrostomy tube (g-tube - a surgically placed tube used to administer medications or food directly into the stomach). LVN 4 failed to safely administer medications via g-tube by failing to follow infection control practices throughout medications administration, for one of seven sampled residents observed during medication administration. This failure to administer g-tube medications for Resident 8 in accordance with professional standards of care and increased the risk for discomfort, clogging of g-tube, infection and contamination of medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that staff used a communication board (tool used for communicating with residents that speak another language) for one of four sampled residents (Resident 100) as written in her care plan. This deficient practice had a potential for staff to ineffectively communicate with Resident 100's care and had a potential to delay medicating Resident 100 when she complained of being in pain.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure one of one sample resident (Resident 53) received rehabilitation services or Restorative Nursing Aide ([RNA] nursing aide program that helps residents to maintain their function and joint mobility) services for the right-hand contracture. (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). This failure had the potential to result in Resident 53 being at risk for further range of motion (ROM - the extent of movement of a joint) decline and contracture.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 66) was not left un-attendant in bed prior to transfer to a mechanical lift (Hoyer lift- (a device used to assist with transferring and moving individuals who have limited mobility) and bed should be locked. This failure had the potential for Resident 66 to fall out of bed and sustain injuries that require hospitalization.

Inspectors wroteBased on interview and record review the facility failed to ensure one of one sample resident (Resident 47) was provided with indwelling urinary catheter (a flexible tube inserted into the bladder to drain urine) care based on professional standards of practice and Resident 47's physician order. This failure had the potential for Resident 47 to develop a urinary tract infection (UTI- an infection in any part of the urinary system, the kidneys, bladder or urethra) and unable to assess Resident 47's intake and output.

Inspectors wroteBased on interview and record review, the facility failed to ensure an annual performance evaluation (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics in performing that an individual needs to perform work roles or occupational functions successfully) was performed every year for Certified Nursing Assistant (CNA ) 2. This deficient practice had the potential for the facility not be able to assess the skills necessary for CNA 2 to provide nursing services to assure resident safety and to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.

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 two of seven sampled residents (Residents 40 and 80) by failing to:1. Administer Resident 40's artificial tears eye drops in the correct eye in accordance with physician orders.2. Administer Resident 80's metformin (a medication used to treat high blood glucose) within one hour of its scheduled time of administration as per facility's policy and procedure (P&P) titled, Medication Administration, dated 4/2025. These deficient practices resulted in a medication administration error rate of 5.71%, which exceeded the 5% threshold and had the potential to cause eye complications for Resident 40, hyperglycemia (high blood glucose) for Resident 80 and hospitalization for Residents 40 and 80.

Inspectors wroteBased on interview and record review, the facility's Quality Assessment and Assurance Committee (QAA) failed to ensure effective oversight and implementation of the facility's plan of correction (POC) of the deficient practices identified during the last recertification survey in 2024. This failure resulted in the facility to have repeat deficiencies in pharmacy services, quality of care and infection control.

Inspectors wroteBased on interview and record review, the facility failed to implement and follow its protocol for antibiotic (medicine used to kill bacteria and treat infections) use on one of four sampled residents (Resident 55). This failure had the potential for Resident 55 to receive an inappropriate antibiotic which could lead to antibiotic resistance (occurs when bacteria evolve and develop the ability to withstand the effects of antibiotics, rendering these drugs ineffective).

Inspectors wroteBased on interview and record review the facility failed to ensure five of five sampled employees Certified Nursing Assistant (CNA) 2, CNA 5, , CNA 6, Licensed Vocational Nurse (LVN) 4, Director of Rehabilitation (DOR) and CNA 4 were offered the Covid-19 (an infectious disease caused by the SARS-CoV-2 virus) vaccine (a substance that is put into the body of a person to protect them from a disease) .This failure had the potential to place all residents and staff at risk for infection of Covid 19.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) was free from verbal abuse when Licensed Vocational Nurse (LVN) 2 cursed at her. This deficient practice resulted in Resident 2 feeling unsafe when LVN 2 was working in the facility. This deficient practice had the potential to cause psychosocial (mental, emotional, and social) harm.

Inspectors wroteBased on interview and record review, the facility failed to implement its abuse reporting and prevention policy titled, unusual Occurence Reported dated 8/2018 by failing to report an unusual occurrence of swelling of the left thigh due to unkown source, to the appropriate State Agencies, including the California Department of Public Health (CDPH) and the local Ombudsman, within 24 hours after the incident occurred for one of one sampled resident (Resident 1). As a result of the facility's failure to report Resident 1's left thigh swelling due to unknown source CDPH ' s investigation regarding the circumstances of Resident 1's injury was delayed. This deficient practice placed Resident 1 and other totaly dependent residents with severely impaired cognition (ability to think, understand, learn, and remember), to be at-risk for abuse, neglect, or mistreatment. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident, who had a history of acute stroke ([CVA]- loss of blood flow to a part of the brain) and complained of having a slurred speech, a headache, and severe pain in left arm was timely transferred to a general acute care hospital (GACH) to prevent ischemic (a condition that occurs when blood flow to an organ, muscle group, or tissue is reduced resulting in a lack of oxygen) stroke for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure Licensed Vocational Nurse (LVN unknown) assessed Resident 1 when Certified Nursing Assistant (CNA) 1, reported on 1/9/2025 at 1 p.m. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure Resident 2 who has repeated threatening and abusive behavior was monitored for one of three sampled residents. This failure resulted in Resident 1 ' s being verbally abused and threatened by Resident 2.

Inspectors wroteBased on interview and record review the facility failed to ensure resident was turned every 2 hours to prevent the progression of a pressure injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence)as care planned for one of three sampled Residents (Resident 3) This failure had the potential to result in Resident 3's pressure injury to worsen and develop an avoidable pressure injury.

Inspectors wroteBased on interview and record review, the facility failed to observe infection control measures by failing to perform a Covid test ( screening test to rule out Covid-19 illness) on one of four sampled residents (Resident 2) who was showing signs and symptoms of a respiratory illness in a timely manner. This failure had the potential to put other residents and staff at risk for infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) will be offered to get out of bed in a wheelchair when resident ' s motorized wheelchair broke down. This failure put Resident 1 at risk for immobility and feelings of isolation and sadness.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident, who was admitted with intact skin did not develop a pressure injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) while in the facility, and a resident who was admitted with a pressure injury had measures in place to prevent the existing pressure injury from getting worse for two of two residents (Resident 2 and 12). The facility failed to: 1. Implement Resident 2's care plan, titled Alteration in Skin integrity intervention to turn and reposition the resident at least every two hours and as needed from 1/2024 to 3/2024 to prevent Resident 2 from developing the pressure injuries to the right and left lateral (to the side of, or away from, the middle of the body) malleolus (the bone on the outside of the ankle joint). 2. [...]

Inspectors wroteBased on interview, and record review the facility failed to provide rehabilitative services (services that help the resident keep, get back, or improve skills of functioning for daily living), as ordered by the physician, for one of one resident ' s (Resident 2). The facility failed to: a) Ensure Resident 2 received speech therapy (treatment that improve ability to talk and swallow) services three times a week, for the week of 3/5/2024. b) Ensure Resident 2 had documented evidence of Restorative Nursing Assistant (RNA) application of the bilateral (both) knee splints (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) from 3/15/2024 to 3/31/2024. These deficient practices placed Resident 2 at risk for not restoring or maintaining highest level of function.

Inspectors wroteBased on interview, and record review the facility failed to ensure one of two resident ' s (Resident 2) documentation was complete and accurate when Resident 2 ' s left lateral malleolus (the bone on the outside of the ankle joint) pressure injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) was described differently. Resident 2 ' s Wound consultant notes for 3/5/2024 indicated the pressure injury was a Stage III pressure injury (full-thickness loss of skin, dead and black tissue may be visible) and Resident 2 ' s Preliminary wound consultant notes for 3/5/2024 indicated it was an unstageable (when the stage is not clear because the base of the wound is covered by a layer of dead tissue) pressure injury. The deficient practices indicated an inaccurate depiction of Resident 2 ' s status.

Inspectors wroteBased on interview and record review, the facility failed to ensure a verbal and physical altercation between two of six sampled residents (Resident 2 and Resident 6) was reported to the Administrator (ADM) and/or to the California Department of Public Health (CDPH), when Certified Nursing Assistant witnessed Resident 2 and Resident 6 throwing oatmeal at each other on 9/13/2024, and when Restorative Nursing Assistant 1 (RNA 1) witnessed a verbal altercation between Resident 2 and Resident 6 on 9/14/2024 and reported it to the ADM. This deficient practice resulted in the inability of CDPH to investigate the Resident to Resident altercations between Resident 2 and Resident 6 in a timely manner and had the potential for facts related to the allegations to be forgotten by staff and other witnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a Hemodialysis Nurse 1 ([HDN 1] licensed nurses who specialize in the care of patients with kidney failure including treatment using hemodialysis [a lifesaving treatment and procedure for kidney failure that removes waste and extra fluids from the blood and regulates blood pressure]) and a Hemodialysis Technician 1 ([HDT 1] a healthcare professional who provides care to patients with kidney failure by performing and monitoring dialysis treatments) cleansed their hands using an alcohol-based hand rub (ABHR) or soap and water, and donned proper personal protective equipment ([PPE] clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments), a gown and gloves, before providing direct care to two of six sampled residents (Resident 7 and Resident 8). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a verbal altercation between two of six sampled residents (Resident 2 and Resident 2) that occurred on 9/14/2024, was investigated. This deficient practice resulted in the incident between Resident 2 and Resident 6 not being addressed and had the potential for continued conflict between the two residents.

Inspectors wroteBased on interview and record review, the facility failed to re-admit one of three sampled residents (Resident 1), when Resident 1 was transferred to a General Acute Care Hospital (GACH) for evaluation of aggressive behavior, increased agitation, and refusal of care. The GACH cleared Resident 1 to return to the facility on 5/9/2024 but the facility refused to readmit her. This deficient practice resulted in Resident 1 remaining at the GACH (over five months after being transferred) and had a potential for Resident 1's continued displacement. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and preparation practices for 89 of 89 residents when: 1. The inside compartment of the ice machine was observed with black residue. 2. A dented can of applesauce was not separated from the ready to use cans in the dry storage area. These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illnesses in all residents who received food and ice from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Infection Preventionist (a person designated by the facility to be responsible for the infection prevention and control program) nurse (IPN) attended, participated, and gave findings on a regular basis to the Quality Assurance and Performance Improvement ([QAPI] a systematic, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes while involving all nursing home caregivers in practical and creative problem solving) committee during monthly meetings. This deficient practice prevented the QAPI Committee from receiving updated information regarding the facility's infection prevention program which had the potential to negatively impact residents' safety regarding infection control practices and outcomes in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement infection control practices by failing to: 1. Date Resident 29's peripheral intravenous catheter ([PIV] a small catheter placed into a vein to administer medication or fluids). 2. Change Resident 57's ventilator (a machine or device used medically to support or replace the breathing of a person who is ill, injured, or anesthetized) tubing per the facility policy. These deficient practices had the potential to result in phlebitis (infection/inflammation of the vein) for Resident 29 and pneumonia (infection of the lungs) for Resident 57. 3. Ensure Resident 26's nebulizer (a device used to administer medication in the form of a mist inhaled into the lungs) mask and tubbing was properly stored or changed as indicated in the facility's policy and procedure (P&P). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 12 sampled residents (Resident 15 and 77) were provided care and services to maintain good grooming and personal hygiene by failing to provide fingernail care for Residents 15 and 77 who were unable to carry out activities of daily living to maintain good personal hygiene. This deficient practice caused Resident 15's long fingernails to dig into the palm of his right hand and had the potential to cause an open wound which could lead to infection. This deficient practice also had the potential to negatively impact Residents 15's and 77's quality of care and self-esteem.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of six sampled residents' (Resident 19) call light was within reach. This deficient practice had the potential to negatively impact Resident 19's quality of life and resident rights to have reasonable accommodations of needs.

Inspectors wroteBased on interview, and record review, the facility staff failed to notify the psychiatrist when resident developed episodes of yelling for one of three sampled residents (Resident 19). This deficient practice had the potential to result in lack of necessary care, treatment, and delay medical interventions for Resident 19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to transmit to Centers for Medicare & Medicaid Services (CMS) the quarterly Minimum Data Set ([MDS] a resident screening and assessment tool) according to regulatory requirements for one of one resident (Resident 65) in a timely manner due to incomplete Section D (Mood) and E (Behavior). This deficient practice can potential negatively affect the delivery of necessary care and services for Resident 65.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a person-centered care plan (document that helps nurses and other team care members organize aspects of resident care) with interventions (actions a nurse takes to implement a care plan, intend to improve the patient's comfort and health) for three of 12 sampled residents (Resident 1, 3, and 15) by failing to: 1. Develop a care plan for Resident 3 who required maximal assistance (helper does more than half of the effort) to dependent assistance with her activities of daily living ([ADLs], self-care activities such as bathing, toileting, and eating) and had unclear speech. 2. Develop a care plan for Resident 15 who received oxygen administration. 3. Develop a care plan for Resident 65 who required maximal assistance with his ADLs. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 15) remained on continuous oxygen at 3 liters per minute via nasal cannula (a device that gives additional oxygen through your nose) as ordered by the physician. This deficient practice had the potential to result in complications from lack of sufficient oxygen for Resident 15.

Inspectors wroteBased on observation, interview, and record review, the facility failed to effectively manage resident's pain for one of one resident (Resident 27) by: 1. Failing to identify the resident's pain level after the administration of routine pain medication. 2. Failing to offer additional pain medication as ordered by the physician when Resident 27 continued to have pain 30 minutes after administering routine pain medications. These deficient practices caused Resident 27 to experience pain that interfered with activities of daily living and resulted in Resident 27 experiencing unrelieved pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a dialysis (the process of removing waste products and excess fluid from the body) emergency kit ([e-kit], contains supplies such as tape, clamp, and gauze to use in case the resident experienced bleeding from their dialysis access site) was readily available at the bedside for one of three sampled residents (Resident 192). This deficient practice had the potential for Resident 192 to receive delayed intervention during accidental bleeding and could lead to hypotension and shock.

Inspectors wroteBased on observation, interview, and record review, the facility failed to document the medication administration of controlled substances (drugs with accepted medical use but with an abuse potential) for one out of three residents (Resident 27). This deficient practice had the potential to harm Resident 27 by the likelihood of medication errors resulting from an inaccurate medical record, and also had the potential to cause Resident 27 harm by potentially not receiving the medication due to the loss of accountability which affects the control against drug loss (any loss of a controlled substance), diversion (transfer of a legally prescribed controlled substance from the individual for whom it was prescribed to another person for any illicit use), or theft.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication error rate of five percent or less by failing to: 1. Check for gastrostomy ([g-tube] a surgical opening into the stomach for food and medication administration) tube placement (inserting air via a syringe into the g-tube and listening with a stethoscope to ensure the g-tube has not dislodged) for Resident 50 per policy and procedures (P&P). 2. Verify Resident 50 received the correct dose of Ferrous Sulfate (an iron supplement) 330 milligrams ([mg] a unit of weight measurement) per 7.5 milliliters ([ml] a unit of liquid measurement). 3. Ensure Resident 50's head of bed was greater than 30 degrees per P&P prior to administering medication via g-tube. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately label and discard expired medications and supplies, to ensure safe medication administration and diagnostic testing by failing to: 1. Ensure 69 packets of expired (2/9/2023) Banatrol Plus ([Banatrol] an antidiarrhea prebiotic supplement) and four (4) bottles of expired (11/2023) ultrasound gel was discarded from the medication storage room. 2. Label Artificial Tears (hydrating solution for dry eyes) eyedrops and Procure Miconazole Nitrate 2% (antifungal powder) with resident name and instructions. These deficient practices had the potential to administer expired medications with substandard therapeutic (producing a favorable result or effect) effects, administer medications not ordered, and to cross contaminate/ spread infection when medications were shared with other residents.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician and/or the Nurse Practitioner (NP) when one of three sampled residents (Resident 1) aspirated (accidentally inhaling food or liquid through the vocal cords into the airway instead of swallowing through the food pipe) and vomited during feeding. This deficient practice resulted in a delay in treatment and a delay in transfer to a General Acute Care Hospital (GACH) for further evaluation and had the potential for Resident 1 to develop aspiration pneumonia (a type of pneumonia that occurs when a person breathes in food, liquid, or other substances into their lungs instead of swallowing them).

Inspectors wroteBased on interview and record review, the facility failed ensure the Respiratory Therapist ([RT] a medical professional who works with patients who have breathing problems or other lung conditions) obtained orders from the physician/nurse practitioner (NP) prior to changing ventilator settings (used ot control how much and how fast air is delivered to a patient's lungs) for one of three sampled residents (Resident 1) and Registered Nurse Supervisor 1 (RNS 1) and RNS 2 followed the recommendations of Resident 1's NP to transfer Resident 1 to a General Acute Care Hospital (GACH) when Resident 1's respiratory rate (RR) was abnormal and showed no signs of improvement. These deficient practices resulted Resident 1 receiving treatment that was not prescribed by Resident 1's physician or NP and a delay in transferring Resident 1 to a GACH for evaluation and treatment. [...]

Inspectors wroteBased on interview and record review, the facility ' s Quality Assessment and Assurance ([QAA] a group which develops and implements appropriate plans of action to correct identified quality deficiencies) committee and Quality Assurance Performance Improvement ([QAPI] a group who takes a systemic, interdisciplinary, comprehensive, and data driven approach to maintaining and improving safety and quality in nursing homes while involving residents and families) committee failed to: 1. Have a policy and procedure (P&P) in place regarding the management and care of residents with the diagnoses of seizures, convulsions, and epilepsy, including how to identify those residents at risk and implement seizure precautions. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1), who resided at the facility and was transferred to a General Acute Care Hospital (GACH) for evaluation and treatment of an elevated heart rate, was readmitted to the facility after Resident 1 was treated and stabilized at the GACH. This deficient practice resulted in Resident 1 remaining at the GACH for five days after Resident 1 was deemed appropriate for discharge back to the facility but was denied readmission by the facility. Resident 1 was subsequently transferred to a different facility, placing the resident at risk for confusion, disorientation and psychosocial harm related to dislocation from a place that was considered Resident 1's home.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) who experienced an assisted fall, sustained a right proximal fibula fracture (a break in the bone below the knee) and was assessed with pain, received pain medication to relieve his pain, per Resident 1's physician's order. This deficient practice resulted in Resident 1's unrelieved and increasing pain for approximately seven hours after falling and sustain a right proximal fibula fracture (12/18/2023).

Inspectors wroteBased on interview and record review, the facility failed to ensure the Family Member (FM 1) was notified when one of four sampled residents (Resident 1) fell on [DATE] at 2:15 a.m., 4:25 a.m., and 6:30 a.m. This deficient practice resulted in Resident 1 ' s FM 1 being unaware of Resident 1 ' s falls and had the potential to interfere with FM 1 ' s informed care decisions.

Inspectors wroteBased on interview, and record review, the facility failed to report an allegation of physical abuse to the California Department of Health (CDPH), the State Long Term Care Ombudsman (an agency that provides support for residents of nursing homes, board and care homes and assisted living facilities) and the local Police Department within the regulated time frame of two hours for one of four sampled residents (Resident 1). This deficient practice resulted in a delay in the CDPH ' s investigation of the physical abuse allegation and had the potential for pertinent data to be lost and/or forgotten.

Inspectors wroteBased on interview and record review, the facility failed to ensure three of seven sampled residents (Resident 1, Resident 5, and Resident 6) living condition were: a. free from direct/ indirect threatening remarks and acts of violence from a non-resident or visitor; and, b. free from noise or disruption from a visitor when their respective care and treatment is being provided. These deficient practices have resulted to Resident1, Resident 5 and Resident 6 to feel disrespected and unsafe in their environment and had the potential to negatively impact their physical and psychological well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure the primary physician 1(MD 1) recorded the cause of death in the progress notes; and completed and filed for a death certificate following one of one sampled resident's (Resident 1) death, as indicated in the facility ' s policy and procedure (P&P). This deficient practice delayed the necessary post mortem (after death) services for Resident 1.

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent the development of an avoidable Stage IV (skin damage that extends to the muscle, tendon, or bone) pressure sore (skin injury from prolonged pressure on the skin and tissue underneath) on the sacro-coccyx (tail bone area) area for one of two sampled residents (Resident 2) by failing to: a. Ensure Resident 2 was repositioned at least every two hours, as indicated in the care plan to relieve the pressure from the sacro-coccyx area. b. Ensure Licensed Vocational Nurse (LVN) 2 assessed Resident 2's sacro-coccyx pressure sore on 5/15/2023, 5/22/2023, 5/29/2023, 6/5/2023, 6/12/2023, and 6/19/2023, to reflect the size of the pressure sore and to reflect the correct classification of the pressure sore as a Stage III (damage extend to fat tissue) pressure sore. c. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure nutritional interventions were evaluated to prevent unplanned weight loss for 1 of 1 resident (Resident 42) by failing to: 1. Ensure facility developed a comprehensive care plan for Resident 42 to include past medical history/surgery and identify the resident's food preference. 2. Revise and develop an effective care plan after Resident 42 had significant weight loss and prevent further weight loss. 3. Provide a therapeutic diet, that considers the resident's clinical condition, and preferences, when there is a nutritional indication. These deficient practices resulted in Resident 42 (R42) to experience severe unplanned weight loss of 5.39% in 3 months and 12% in 90 days (previous admit weight was 186 pounds).

Inspectors wroteBased on observation, interview and record review, the facility failed to identify, provide a comprehensive assessment and treatment for a change of condition (COC) for one of two (2) sampled residents (Resident 55 and 237) with hypoxia (not enough oxygen in the tissues to sustain bodily functions) and altered mental status(confusion/disorientation). These deficient practices resulted in Resident 55 and 237 receiving delayed provision of care and treatment, and transfer to a local acute care hospital.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a spare tracheostomy tube kit was at the bedside for emergency use for one of three sampled residents (Resident 9). This failure had the potential to delay emergency treatment and further complicate resident 9's respiratory status.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of four sampled residents (Resident 75) who received hemodialysis (a medical procedure to remove fluid and waste products from the body) had the necessary supplies (clamp) to stop bleeding in the emergency kit at Resident 75's bedside. This deficient practice had the potential for resident 75 to receive delayed intervention during accidental bleeding.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess, obtain consent and orders for, and care plan restraint use for one of two (2) sampled residents (Resident 240). This deficient practice had the potential to result in Resident 240 sustaining injuries from being caught in between the rails or falling in attempts to climb over the rails, which would require additional care and treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure the physicians initial face-to-face visit was made within 72 hours after admission for one of 18 sampled residents (Resident 28). This deficient practice had the potential to result in an undetected decline in medical, health or psychosocial condition and can lead to a delay in necessary care, treatment, and services.

Inspectors wroteBased on interview and record review the facility failed to act upon the consultant pharmacist's recommendation in the Medication Regime Review (MRR), to clarify the indication for use of Haldol and Zyprexa (psychoactive medication-any medication capable of affecting the mind, emotions, and behavior) with the physician for one of four sampled residents (Resident 28) for unnecessary medications review. This deficient practice had the potential to cause Resident 28 to receive an unnecessary medication and can lead to adverse side effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nursing staff performed proper hand hygiene and disinfection of wound care supplies for one of four (4) sampled residents (Resident 240) during wound care provision. These deficient practices had the potential to transmit infectious microorganisms and increase the risk of infection for Resident 240.