Pasadena Nursing Center

Inspectors wroteBased on observation, interview and record review, the facility failed to protect two (2) of three (3) sampled residents (Resident 1 and Resident 2) from verbal abuse (the use of oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability) based on the facility's policy and procedure. This deficient practice had resulted in Resident 1 and Resident 2 experiencing verbal abuse which could affect both of the residents emotional and psychosocial wellbeing. Findings1. [...]

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of verbal abuse (the use of oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability) for one (1) of two sampled residents (Resident 8) within a 2-hour timeframe to the State Survey Agency (SA, where state law provides for jurisdiction in long-term care facilities), the state ombudsman (advocates for residents of nursing homes, board and care homes and assisted living facilities), and local law enforcement based on the facility's policy and procedure. This deficient practice had the potential to compromise or impede the protection of Resident 1 and Resident 2 which could affect resident's emotional and mental wellbeing.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services in accordance with the facility's policies and procedures (P&P) by failing to ensure two (2) licensed nurses witnessed the disposition of discontinued medications and record accurately. This deficient practice had the potential to result in the inability to identify loss of medications and potential for drug diversion (illegal distribution or abuse of prescription medications or their use for unintended purposes).

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy for discarding and disposing of medications by failing to:Discard one (1) expired Lantus (long acting man-made insulin used to control high blood sugar) injectable pen (portable, easy to use device used by people with diabetes [chronic condition where the body either cannot produce enough insulin or cannot use it properly] to inject insulin) which was stored in Medication Cart 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent physical abuse (intentional bodily injury) for one (1) of four (4) sampled residents (Resident 1) when Resident 2 hit Resident 1 on the face on 4/27/2026. This failure had the potential to result in mental and emotional distress for Resident 1.1. During a review of Resident 1's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of paranoid schizophrenia (a chronic mental condition where a person loses touch with reality through intense, irrational distrust) and anxiety disorder (a mental health condition characterized by persistent, excessive, and uncontrollable fear or worry that interferes with daily life). [...]

Inspectors wroteBased on interview and record review, the facility failed to inform and a provide written information to formulate an advanced directive (written statement of a person's wishes regarding medical treatment which were made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) for two (2) of 2 sampled residents (Resident 13 and 20) reviewed for advanced directives, as indicated on the facility policy. This deficient practice had the potential to cause conflict in carrying out Resident 13 and 20's wishes for medical treatment and resident's health care decisions.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe, clean and homelike environment for two (2) of four (4) sampled residents (Resident 14 and 27) reviewed for environment, as indicated on the facility's policy, when:Resident 14 was observed sitting on a bed that has no bed sheet to cover the mattress, leaving the mattress' surface exposed. Resident 27's brown pillow, which had fallen into a trashcan, was not cleaned or replaced, and was placed back to the resident's freshly made bed. The facility did not ensure no cup of juice was left by the bariatric Geri chair (a heavy duty mobile recliner with a wider seat [often 22 to 36 inches] and a higher weight capacity [typically 350 to 700 plus pounds] designed to assist plus size patients with mobility issues in transitioning from bed to a comfortable, supported sitting position) by the hallway. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately measure the mozzarella cheese used to prepare the spinach au gratin served for lunch on 4/15/2026. This deficient practice had the potential to result in meal dissatisfaction, decreased nutritional intake, and weight loss for the 32 residents who received the spinach au gratin.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the food service area in a clean and sanitary condition and failed to follow its proper food handling procedures to ensure food safety by failing to ensure: 1. Maintain the refrigerator with sufficient space to allow for proper internal air flow2. The can opener was not chipped along the metal blade area, and it was free from a hair-like residue from green cleaning pad. These deficient practices have the potential to result in pathogen (germ) exposure to residents, which could place the residents at risk for developing foodborne illness ([food poisoning] with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever) and can lead to other serious medical complications and hospitalization.

Inspectors wroteBased on interviews, and record review, the facility failed to coordinate a Level II Preadmission Screening and Resident Review (PASARR, initial screening for all applicants to Medicaid-certified nursing facilities [meets federal and state standards for care and is approved to receive payment from Medicaid {a government health insurance program that provides free or low-cost coverage to eligible low-income individuals and families} for services provided to eligible residents] for possible serious mental disorder [MD, a health condition characterized by clinically significant alterations in thinking, mood, or behavior associated with distress and/or impaired functioning], intellectual disability [ID, a condition characterized by significantly subaverage intellectual functioning and substantial limitations in adaptive behavior] or a related condition, which is completed prior to admission [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the environment was free of accident hazards by placing a box fan (a square-shaped electric fan) on top of a four (4) - wheeled walker (a mobility aid with a 4 pronged base and rubber tips designed to provide more stability and support that a standard single-point cane) in the foot area of the resident's room for one (1) of three (3) sampled resident (Residents 13) reviewed for accidents, in accordance with the facility policy. This deficient practice placed Resident 13 at risk for injury and serious harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (1) of 1 sampled resident (Resident 35) reviewed for hydration, was provided with bedside water to maintain proper hydration. This deficient practice has the potential to put the resident at risk for dehydration (a condition occurring when the body loses more fluids, primarily water).

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to ensure one (1) of two (2) medication carts were locked and unattended in the hallway, as indicated on the facility's policy. This deficient practice had the potential for non-authorized staff or residents to access the medication cart, which could result in diversion or if the medications were ingested, may cause serious injury/harm to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to coordinate hospice care (compassionate care for people who are near the end of life provided at the person's home or within a health care facility) with Hospice Agency for one (1) of two (2) sampled residents (Resident 18) reviewed for hospice in accordance with the facility's policy by failing to ensure Resident 18 had:1. A physician's order of the required visits by the hospice staff (Skilled Nursing [SN], Hospice Aid [HA], Social Worker [SW], and Spiritual Care [SC).2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to observe infection control measures for one (1) of 1 sampled resident (Residents 7) reviewed for tube feeding (a medical method of delivering liquid nutrition, fluids, and medications directly into the stomach or small intestine through a soft, flexible tube) by failing to ensure Resident 7's Gastrostomy tube (GT- tube feeing via the) was not touching the floor. This deficient practice can result in contamination of the resident's care equipment (tube feeding) and place the residents at risk of infection. [...]

Inspectors wroteBased on interview and record review, the facility failed to offer and provide Influenza (flu, a contagious respiratory illness caused by influenza viruses that infect the nose, throat, and lungs) immunization for one (1) of five (5) sampled residents (Resident 13) reviewed for infection prevention, control, and immunizations (process of protecting a person from a disease by giving a vaccine that helps the body build immunity). This deficient practice had the potential to increase Resident 13's risk of infection and suffer from severe complications such as pneumonia (lung infection), hospitalization, and death.

Inspectors wroteBased on interview and record review, the facility failed to offer and provide Coronavirus-19 (Covid-19, an acute respiratory illness in humans caused by coronavirus, capable of producing severe symptoms and in some cases death, especially in older people and those with underlying health conditions) immunization for one (1) of five (5) sampled residents (Resident 13) reviewed for infection prevention, control, and immunizations (process of protecting a person from a disease by giving a vaccine that helps the body build immunity) in accordance with the facility policy. This deficient practice had the potential to increase Resident 13's risk of acquiring and transmitting Covid-19 virus to other residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light was within resident's arm's reach for one (1) of four (4) sampled residents (Resident 2) reviewed for environment in accordance with the facility's policy. This deficient practice had the potential for Resident 2 not to be able to call the facility staff for help or assistance, especially during an emergency.

Inspectors wroteBased on interview and record review, the facility failed to ensure an accurate assessment of the Minimum Data Set (MDS, a resident assessment tool) for one of two sampled residents (Resident 1) to reflect the resident's functional ability of walking. This deficient practice had the potential for the facility not to develop and implement an individualized care plan (a document that outlines the facility's plan to provide personalized care to a resident that includes measurable objectives, interventions and timeframes to meet a resident's medical, nursing, and mental psychosocial needs) which could negatively affect Resident 1's overall well-being.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from physical abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) for one of two sampled Residents (Resident 1) when Resident 2 punched Resident 1's face on 3/9/2026. This failure resulted in Resident 1 having a skin tear to the left upper lip and possible psychosocial harm.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) and resident's responsible party (RP) were notified and given an opportunity to participate in the care planning process for the development and implementation of the resident's person-centered plan of care. This deficient practice had the potential to prevent Resident 1 and the RP from exercising their right to participate in care planning and informed decision making to support the resident's goals, choices, and preferences.

Inspectors wroteBased on interview, and record review, the facility failed to fully inform the resident's conservator (a person or organization appointed by a court to manage the personal car, finances, or both, of an adult who can no longer make their own decisions due to physical or mental limitations) in advance, of the risks and benefits of proposed care for one (1) of two (2) sampled residents (Resident 1) in accordance with the facility policy when an informed consent was not obtained prior to residents use of the following three (3) psychotropic medications (mind - altering or mood-regulating medications). 1. Paliperidone (drug used to treat schizoaffective disorder [a mental illness that can affect thoughts, mood, and behavior] and schizophrenia [a mental illness that is characterized by disturbances in thought]).2. Haldol (drug used to treat schizophrenia).3. [...]

Inspectors wroteBased on interview, and record review, the facility failed to maintain accurate documentation of Hospice (compassionate care for people who are near the end of life) Care Service notification of the refusal of the psychotropic medications (mind - altering or mood-regulating medications) for one (1) of two (2) sampled residents (Residents 2). This deficient practice resulted in the medical records inaccurate representation of care provided to Resident 2 and had the potential to result in miscommunication between health care providers to ensure the resident's behavioral problems were accurately addressed.

Inspectors wroteBased on interview and record review the facility failed to report an alleged abuse (willful infliction of injury resulting to physical harm/ pain or mental anguish) to the State Survey Agency (California Department of Public Health-CDPH - where state law provides for jurisdiction in long-term care facilities), ombudsman (OMB) (advocates for residents of nursing homes, board and care homes and assisted living facilities), and local law enforcement when OMB and local law enforcement (PD) in accordance with State law within two (2) hours after the allegation was made for two of two sampled residents (Resident 1 and Resident 4). This deficient practice had the potential to place Resident 1 and Resident 4 at risk for further abuse and/or under reporting from the facility.

Inspectors wroteBased on interview and record review, the facility failed to administer medication in accordance with the physician's order and to ensure that the administration of controlled medications (a drug or chemical whose manufacture, possession, and use are regulated by the government due to its potential for abuse or addiction) were accurately documented in the Medication Administration Record (MAR) for two (2) of two sampled residents (Resident 2 and 5). This deficient practice had the potential for harm to Resident 2 and 5 due to missed medications and due to an inaccurate record of controlled medication use, and the possible loss of accountability, which could affect the controls against drug loss, diversion, or theft.

Inspectors wroteBased on interview and record review the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards and practices for three (3) of 3 sampled residents (Residents 2, 3, and 4) when Licensed Vocational 1 (LVN 1) and LVN 2 did not document medications administered from 3 PM to 11 PM on 11/25/2025 in the residents' Medication Administration Record (MAR). This deficient practice had the potential to result in a lack of or a delay in delivery of necessary care or services and in medication errors.

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure that the facility followed proper food handling practices in accordance with the professional standards for food service safety (the rules, regulations, and guidelines that ensure food is handled, prepared, and stored to prevent foodborne illnesses [also known as food poisoning, it is a condition that occurs when consuming contaminated food or beverages]) such as prevention of cross-contamination, maintaining equipment and surfaces in clean, sanitary condition, by failing to:1. Ensure the facility did not prepare the residents' meals in the facility's kitchen with a large gaping hole that measured three (3) feet (ft.- unit of measurement) by four (4) ft. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the facility's policy and procedure (P&P) for Abuse Investigation and Reporting for two of three residents (Resident 1 and Resident 2) by failing to: 1. Conduct a thorough and complete investigation of an allegation of physical abuse to Resident 1 who was found with scratch marks on the right side of his face and the resident stated someone else had done it on 3/26/2025. 2. Report an allegation of physical abuse to Resident 1 to the State Survey Agency (SA, where state law provides for jurisdiction in long-term care facilities), ombudsman (OMB- advocates for residents of nursing homes, board and care homes and assisted living facilities), and local law enforcement within two (2) hour timeframe from when the allegation was made by the resident on 3/26/2025. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to conduct a thorough investigation of an allegation of physical abuse (intentional act causing injury or trauma to another person by way of bodily contact such as hitting/ scratching/ pinching) to one of three sampled residents (Resident 1) who was found with scratch marks on the right side of his face and the resident stated someone else had done it on 3/26/2025. This deficient practice resulted in compromising the safety of Resident 1 and placed the resident at risk for further physical abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the low air loss mattress (LALM- a specialized medical mattress designed to prevent and treat pressure ulcer [wound that occurs as a result of prolonged pressure on a specific area of the body]) by maintaining a cool, dry environment through constant airflow, which helps regulate temperature and moisture) was on the correct setting for two (2) of 2 sampled residents (Resident 11 and Resident 29) in accordance with the physician's orders and LALM operator's manual instructions. This deficient practice placed Residents 11 and 29 at risk of poor wound healing and deterioration (something once in good condition is now weakened, worn out, or otherwise in decline) of current pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the facility's smoking policy for three (3) of 3 sampled smoking residents (Resident 4, 14, and 152). Residents 4, 14, and 152 were observed smoking without an apron on 3/17/2025 in accordance with the Smoking Safety Assessment anad/care plan. This deficient practice had the potential to result in harm and injury to the residents in the event of an accidental fire in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the call light (a device used by residents to call for assistance) was placed within reach (an arm's length) for two of 17 sampled residents (Resident 11 and Resident 37). This deficient practice had the potential to result in delayed provision of services and care and assistance with activities of daily ling (ADLs- refers to basic self-care tasks that are necessary for maintaining daily life) which could result in harm to Residents 11 and 17.

Inspectors wroteBased on observation, interview and record review, the facility failed to inform the physician (MD) of a change in condition (any noticeable deviation from a patient's baseline or expected state of health, requiring prompt assessment and intervention) for one (1) of five (5) sampled residents in accordance with the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, after Resident 152 exhibited increased aggression and physically assaulted certified nurse assistant 5 (CNA5) on 3/18/25. This deficient practice had the potential to result in a delay of care and services, which could negatively affect Residents 152's overall wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure germicidal disposable wipes (disinfectant wipes designed to kill a wide range of microorganisms [a living thing that is so small it must be viewed with a microscope] on hard, non-porous surfaces [examples of hard nonporous surfaces include stainless steel, metal, glass, hard plastic, and varnished wood] and not intended to be used on the resident's skin) were not used to sanitize one of 17 sampled residents' (Resident 17) hands prior to providing nail care. This deficient practice had the potential to result in skin irritation and harm to Resident 11.

Inspectors wroteBased on interview and record review, the facility failed to prevent the elopement (a form of unsupervised wandering that leads to the resident leaving the facility) for one of two residents (Resident 252) assessed as at risk for elopement by failing to implement the facility's Wandering and Elopement Policy and Procedures (P&P) by failing to: 1. Develop a care plan to ensure Resident 252 received interventions to prevent elopement when assessed as elopement risk on 11/4/2024. 2. Have documented evidence of Resident 252's family and physician notification when resident eloped and was found on 11/16/2025. 3. Have documented evidence that Resident 252 was examined for injuries upon return on 11/16/2025 and have the relevant information documented in the resident's medical record. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to administer the correct gastrostomy tube (g-tube, tube inserted through the belly that brings nutrition directly to the stomach) formula feeding as ordered by the physician (MD) for one (1) of two (2) sampled residents (Resident 102) in accordance with the facility's policy and procedure (P&P) titled, Enteral Tube Feeding via Continuous Pump. This deficient practice had the potential to cause Resident 102 to have uncontrolled blood sugar, and inappropriate nutrition and worsening of Resident 102's health condition.

Inspectors wroteBased on observation, interview, and record review the facility failed to conduct a monthly Medication Regimen Review (MRR, a monthly thorough evaluation by the consulting pharmacist of a resident's medication regimen, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) for one (1) of five (5) sampled residents (Resident 16) in accordance with the facility's Medication policy and procedure. This deficient practice had the potential to cause Resident 16 to receive unnecessary medication and to potentially have adverse reactions from medications.

Inspectors wroteBased on interview and record review, the facility failed to maintain an accurate resident medical records for one of 17 sampled Residents (Resident 102) by failing to ensure electronic medication administration (eMAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) record was signed after administering resident's 8 AM medications on 3/19/2025. This deficient practice had the potential for staff to not know the medications that were administered to Resident 102 which could result in duplication or no administration of medications which could affect the resident's over all wellbeing.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain an infection prevention control program by failing to label the oxygen tubing (the flexible hose or tube that connects an oxygen source (like a concentrator or cylinder) to a device that delivers oxygen to a resident, such as a nasal cannula [a flexible tube with two prongs, used to deliver supplemental oxygen through the nostrils, often for individuals experiencing breathing difficulties or needing oxygen therapy] or mask [ a device worn over the nose and mouth through which oxygen is delivered]) and enteral feeding tube (a flexible, thin tube inserted into the gastrointestinal [GI] tract [the series of organs and structures that process food and absorb nutrients from it] to provide nutrition or medication directly into the stomach or small intestine) for two (2) of 17 sampled residents (Resident 102 and [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose garbage (mostly decomposable food waste or yard waste) and keep two (2) of 2 garbage dumpsters/refuse (dry material such as glass, paper, cloth, or wood that does not readily decompose) containers covered and/or not overfilled with trash as indicated on the facility policy. These deficient practices had the potential to attract vermin (animals that are believed to be harmful, carry diseases such as rodents, parasitic worms, or insects), pests (any living thing that has a negative effect on humans), and wildlife (undomesticated animal species) that could potentially infiltrate the facility, affect the resident care areas and pose a disease threat to the residents and staff of the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staffing information was complete and posted in a visible and prominent place daily in accordance with the facility's policy and procedure (P&P) titled, Posting Direct Care Daily Staffing Numbers. As a result, the total number of staff and the actual hours worked by the staff was not readily accessible to residents, staff, and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the minimum 80 square feet (sq. ft., unit of measurement) per resident in multiple resident bedrooms for one (1) of 21 resident's rooms (Room A) in the facility. This failure had the potential to affect the residents' personal space, decrease freedom of mobility (the ability to move or be moved freely and easily) and could compromise the provision of care.

Inspectors wroteBased on interview and record review Facility 1 failed to report an allegation of alleged sexual abuse (non-consensual sexual contact of any type with a resident) for one (1) of two sampled residents (Residents 1) within 2-hour timeframe to the State Survey Agency (SA, where state law provides for jurisdiction in long-term care facilities), ombudsman (OMB) (advocates for residents of nursing homes, board and care homes and assisted living facilities), and local law enforcement when OMB and local law enforcement (PD) went to the Facility 1 to investigate the allegation of sexual abuse by Resident 1 to Resident 2. This deficient practice had the potential to result in unidentified abuse in the Facility 1 and failure to protect other residents from abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent physical abuse (willful infliction of injury which includes, but is not limited to, hitting, slapping, punching, biting, and kicking) for one (1) of 2 sampled residents (Resident 1). This failure resulted to Resident 1 striking Resident 2 on the head on 2/7/2025, leaving a lump on the left side of Resident 2 ' s head while Resident 1 suffered right hand swelling.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one (1) of two (2) sampled residents (Resident 2) was free from unnecessary psychotropic drug (any medication capable of affecting the mind, emotions, and behavior) use as indicated in the facility ' s policy and procedure by failing to monitor the behaviors for the use of Klonopin (used to prevent and treat anxiety disorders [fear characterized by behavioral disturbances] and seizures [sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]), Lithium (a mood stabilizer that is used to treat or control the manic [extremely elevated and excitable mood] episodes ), Trazodone (used to treat depression [a mood disorder that causes a persistent feeling of sadness and loss of interest]), and Zyprexa (medication that works in the brain to treat [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to readmit three of seven residents (Resident 1, 2, and 3) after Facility 1 was cleared to repopulate (transfer back residents to the facility from the previous temporary location when residents were evacuated) back their residents on 1/17/2025. This deficient practice resulted in: 1. Resident 1 residing at Facility 2 from 1/17/2025 to 2/7/2025 (22 days) without the knowledge and consent from the resident's responsible party (RP-an individual, or a placement agency, who assists the resident in placement or assumes varying degrees of responsibility for the well-being of the resident, as designated by the resident in writing) to permanently place resident at Facility 2. 2. [...]

Inspectors wroteBased on interview, and record review, facility failed to prevent a fall (move downward, typically rapidly and freely without control, from a higher to a lower level) of one of two sampled residents (Resident 1) by: 1. Failing to revise Resident 1's care plan for moderate risk for fall related to gait/ balance problems after the resident's Minimum Data Set (MDS, standardized care and screening tool) and Physical Therapy Treatment Encounter Notes (PT Note - documents sequential implementation (executing one task at a time, in order)of the plan of care established by the physical therapist, including changes in patient/client status and variations and progressions of specific interventions used) were completed on 7/15/2024 and 7/16/2024 to reflect the resident's, need for partial moderate assistance (helper does less than half the effort. Helper lifts, holds or support trunk or limbs. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the Notice of Transfer/Discharge was completed in its entirety for one of three sampled residents (Resident 1). This deficient practice resulted in an incomplete documentation of Resident 1 ' s transfer/discharge notice which was necessary to communicate information to receiving providers to prevent inappropriate, unnecessary, and untimely transfers and discharges.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the physician and the responsible party for one (1) of two (2) sampled resident (Resident 3) regarding the resident's bruises on the right flank (the side of a person between the ribs and hip) area as indicated in the facility policy. This deficient practice could potentially result in a delay in treatment for Resident 3 affecting the health and well-being of the resident and had violated Resident 3's right to be informed of the care and services provided.

Inspectors wroteBased on interview and record review the facility failed to prevent and stop an incident of verbal abuse (a range of words or behaviors used to manipulate, intimidate, and maintain power and control over someone) for one of two sampled residents (Resident 1) when Resident 2 called Resident 1 racial (discrimination and prejudice against people based on their race or ethnicity) slurs (an insinuation or allegation about someone that is likely to insult them or damage their reputation) and Resident 2 attempted to hit and spitted at Resident 1. This failure placed Resident 1 at risk for psychosocial harm such as feeling unsafe and anxious.

Inspectors wroteBased on interview and record review the facility failed to report within two hours to the state agency (CDPH; California Department of Public Health), the state ombudsman (advocates for residents of nursing homes, board and care homes and assisted living facilities), and local law enforcement (Local PD) of an allegation of verbal abuse (a range of words or behaviors used to manipulate, intimidate, and maintain power and control over someone) for one of two sampled residents (Resident 1). This failure resulted in the facility not reporting the alleged verbal abuse and putting Resident 1 at further risk of more episodes of verbal abuse by Resident 2.

Inspectors wroteBased on interview and record review the facility failed to follow their policy and procedure titled Advance Directive (a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them) for three (3) of 5 sampled residents (Residents 45, 7 and 8) for the advance directive care area by: 1. Not ensuring the Advance Directive Acknowledgement Form notifying Resident 45 of his right to execute an advance directive was fully filled out. 2. Not ensuring a copy of the Advance Directive was readily accessible in Resident 7 and 8's medical chart. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to conduct an assessment and utilize other alternatives prior to use of physical restraints (any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the resident cannot remove easily which restricts freedom of movement) for three(3) of four (4) sampled resident (Residents 50, 37, and 33) for restraint care area, in accordance with the facility policy. This deficient practice had the potential to result in injury to Residents 50, 37and 33's and decline in the residents' quality of life, psychosocial and physical functioning.

Inspectors wrote2. A review of Resident 14's admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of encephalopathy (damage or disease that affects the brain) and schizoaffective disorder (a type of mental illness characterized by symptoms of both schizophrenia [a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness and social interactions] and a mood disorder which includes mania [extreme highs] or severe depression [severe lows]), bipolar type (a mental illness that causes unusual shifts in a person's mood, energy, activity levels and concentration). A review of Resident 14's History and Physical Examination (H&P), dated 6/30/2023, H&P indicated the resident was able to make decisions for activities of daily living. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide appropriate and consistent activities for two of two sampled residents (Resident 7 and 21) for the activities care area. This failure had the potential to decrease the physical wellbeing, sense of belonging and emotional health for Resident 7 and 21.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Low Air Loss mattress (LAL mattress, designed to distribute the resident's body weight over a broad surface area and help prevent skin breakdown) was set up accurately for two (3) of three (3) sampled residents (Resident 33, 6, and 29) for pressure ulcer (refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) care area. This deficient practice had the potential for Resident 33 to develop a new pressure ulcer and for Residents 6 and 29's pressure ulcer to worsen.

Inspectors wroteCross reference F759 Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of residents as indicated on the facility policy by: 1. Failing to ensure the narcotic (drug that produces analgesia [pain relief], narcosis [state of stupor or sleep], and addiction [physical dependence on the drug]) count sheet contained two Licensed Nurses' signatures for one of two medication cart 1 (MC 1). This deficient practice had the potential for inaccurate record of narcotic medication use and loss of accountability, which could result to drug loss, diversion, and could potentially harm the resident if ingested. 2. Licensed Vocational Nurse (LVN 2) failed to administer Metoprolol (a medication that lowers your blood pressure and heart rate) twice daily for Resident 38 as indicated in the Physician's order. 3. [...]

Inspectors wroteCross reference: F759 Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%). Eight (8) medication errors out of 27 total opportunities contributed to an overall medication error rate of 29.63 % for three (3) ouf six (6) sampled residents (Residents 38, 157 and 40) observed during medication administration (med pass). 1. Licensed Vocational Nurse (LVN 2) failed to administer Metoprolol (a medication that lowers your blood pressure and heart rate) twice daily for Resident 38 as indicated in the Physician's order. 2. LVN 2 failed to administer Resident 157's medications within one hour of scheduled time of 9 AM. 3. LVN 2 failed to administer Resident 40's medications within one hour of scheduled time of 9 AM. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the kitchen utensils and equipment's were kept clean and maintained in good condition, and to discard expired foods and not stored in the kitchen. These deficient practices had the potential to result in pathogen (germ) exposure to residents and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead to other serious medical complications and hospitalization.

Inspectors wroteBased on observation, interview, and record review the facility failed to promote respect and dignity for one (1) of 1 sampled resident (Residents 40) for the dignity care area by not ensuring: 1. Resident 40's indwelling catheter (soft, plastic or rubber tube that is inserted into the bladder to drain the urine) urine collection bag was inside the dignity bag (a bag used to the cover and hold the catheter drainage/collection bag, so it is not visible). 2. Resident 40's rectal bag (soft, silicone catheters with a retention balloon intended to hold the catheter within the rectum and create a seal, may be used for the temporary management of diarrhea and fecal incontinence, to protect perineal skin and wounds, and to prevent cross infection) was inside the dignity bag.

Inspectors wroteBased on interview and record review, the facility failed to ensure the quarterly Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool) assessment was completed within the required time frame for one (1) of two (2) sampled residents (Resident 12), for Resident Assessment care area, as indicated on the facility Resident Assessment policy. This deficient practice had the potential to not be able to track Resident 12's status between comprehensive assessments to ensure critical indicators of gradual change in resident's status are monitored.

Inspectors wroteBased on interview and record review, the facility failed to develop a person-centered behavioral care plan for one of 21 sampled residents (Resident 49). This failure had the potential to result in Resident 49 not receiving the proper care and interventions.

Inspectors wroteBased on observation, interview and record review, the facility failed to revise the activity care plan for two of 21 sampled residents (Residents 7 and 21) to reflect current needs, preference, abilities, and limitations, in accordance to the facility policy. This failure had the potential to not provide Residents 7 and 21's activities, which could affect residents' mental and emotional well-being.

Inspectors wroteBased on observation and interview, the facility failed to ensure one of 21 sampled resident (Resident 45) for the Activities of Daily Living (ADLs) care area was provided a communication board (a device that displays photos, symbols, or illustrations to help people with limited language skills express themselves) that was readily accessible with the language they're able to understand. This failure had the potential to result in Resident 45 experiencing a delay in receiving appropriate care and treatment due to the staff not being able to properly communicate with the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to check the gastrostomy tube (GT - a flexible tube surgically inserted into the abdomen to stomach for feeding and medication administration) placement before flushing a GT with water for one of two (2) sampled residents (Resident 37) in tube feeding care area. This deficient practice had high risk for Resident 37 to have complications including aspiration.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to ensure one (1) of two (2) sampled residents (Resident 10) received two 2 liters per minute (LPM) of oxygen (the odorless gas that is present in the air and necessary to maintain life) as needed according to physician's order. This deficient practice had the potential to cause complications associated with oxygen therapy (a treatment that provides you with extra oxygen to breathe in).

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled resident (Resident 32) for dialysis (a process by which dissolved substances are removed from a patient's body by diffusion from one fluid compartment to another across a semipermeable membrane) care area, who was receiving hemodialysis (process of removing waste products and excess fluid from the body) treatment was provided dialysis care and services in accordance with the facility policy. This deficient practice had the potential for unnoticed or missed excessive bleeding and infection on Resident 32's dialysis arteriovenous (AV) fistula (vascular access in patients receiving regular hemodialysis).

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess risk for entrapment (an event in which a resident is caught, trapped, or entangled in the space in or about) and attempt alternatives prior to the use of side rails (adjustable metal or rigid plastic bars that attach to the bed) for one of 21 sampled Residents (Resident 7) as indicated on the facility policy. This failure had the potential to result in the inappropriate use of side rails for Resident 7, which could pose a safety risk and result in injury or harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the facility's policy and procedure on storage of controlled medication (a prescription medicine that is subject to strict legal controls) when a bottle of liquid lorazepam (medication used to treat anxiety) was not stored inside a permanently affixed locked box/compartment inside the refrigerator. This deficient practice had the potential for improper use of controlled medication due to easier access which can lead to medication error and to cause residents to be exposed to adverse side effects of the medication.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement its policy and procedure on infection control for two (2) of 21 sampled residents (Resident 33 and 106) when: 1. Hospice staff (HS) did not use personal protective equipment (PPE, used to prevent or minimize exposure and to protect from potential transmission of biological agents that can be transferred from person to person by direct and indirect contact) while rendering care to Resident 33 who has an order for enhanced standard precaution (ESP, use of PPE beyond anticipated blood and body fluid exposures). 2. Resident 106's nasal canula (medical device to provide supplemental oxygen therapy to people who have lower oxygen levels) was not changed per Doctor's (MD) order. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain safe, clean, comfortable sanitary and home like environment for one (1) of four (4) sampled residents (Resident 10) by not ensuring that Resident 10's bathroom trash can was not overflowing with trash, and bathroom toilet was free of fecal matter. These deficient practices caused an unsanitary and had a potential for residents to be placed at risk for injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staffing information was posted and placed in a visible and prominent place on 4/2/2024. As a result, the total number of staff and the actual hours worked by the staff was not readily accessible to residents and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the minimum 80 square feet (sq. ft.) per resident in multiple resident bedrooms for one (1) of 21 Resident rooms (Room C) in the facility. This failure had the potential to affect the residents' personal space, decrease freedom of mobility and could compromise the provision of care.

Inspectors wroteBased on interview and record review, the facility failed to address the wandering behavior of one of four sampled residents (Resident 2) who had episodes of confusion and wandering into other residents ' rooms. This deficient practice resulted in Resident 2 wandering into Resident 1 ' s room and while in the room getting pushed to the floor by Resident 5.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of three sampled residents (Resident 1, 2, and 3) receiving therapy services had complete clinical records. 1. For Resident 3, the facility failed to: a. Complete a weekly Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) Progress Note, which was due on 12/20/2023, and b. Ensure Resident 3 ' s weekly Occupational Therapy [OT, profession aimed to increase or maintain a person's capability of participating in everyday life activities (occupations)] Progress Note was based on an objective assessment (collection of data observed and measured) of Resident 3 ' s performance with self-care. 2. For Resident 1, the facility failed to: a. Complete a weekly PT Progress Note, which was due on 12/23/2023. b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe and healthy environment due to the presence of mold-like substances inside the facility. This deficient practice has the potential to cause symptoms (coughing, postnasal drip, sneezing, itchy eyes, nose, or throat, or nasal congestion) in individuals who have respiratory/mold sensitivity (individuals with a weakened immune system or underlying lung disease are more susceptible to fungal infections) and could trigger respiratory complications.

Inspectors wroteBased on interview and record review, the facility failed to accommodate the preference of one of three sampled residents (Resident 15) to have privacy and not share the resident's restroom with other residents in the facility. This deficient practice had the potential to violate resident's rights, which could result in psychosocial harm

Inspectors wroteBased on interview and record review the facility failed to report within two (2) hour timeframe, an allegation of abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) on 12/20/23 to the State Survey Agency (SA, where state law provides for jurisdiction in long-term care facilities) and local law enforcement for one of two sampled residents (Resident 6), in accordance to facility policy. This deficient practice had the potential to result in unreported abuse in the facility and failure to protect other residents from abuse.

Inspectors wroteBased on interview and record review, the facility failed to permit one of one sampled resident (Resident 6) back to Skilled Nursing Facility 1 (SNF 1) after the resident was hospitalized at the General Acute Care Hospital (GACH). This deficient practice resulted in the violation of Resident 6's right to resume residency at the facility and had the potential to cause psychosocial harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete an accurate Minimum Data Set (MDS, a comprehensive assessment and care planning tool) for one of three sampled residents (Resident 2) who fell on 9/14/2023. This failure resulted in inaccurate assessment of the resident information submitted to the Federal database.

Inspectors wroteBased on interview and record review, the facility failed to provide supervision for two of three sampled residents (Resident 1 and 2), when Resident 2 was found naked while sitting next to Resident 1 who was in bed on 12/1/23. Resident 1 was also found naked on the lower part of her body. This deficient practice had the potential for Resident 1 to be sexually assaulted (sexual contact or behavior that occurs without explicit consent of the victim) by Resident 2.

Inspectors wroteBased on interview and record review the facility failed to ensure one of four sampled residents (Resident 2) received medication as prescribed by the physician and to inform the physician of the missed medications. This deficient practice had the potential for Resident 2 to have aggressive behavior towards self and other resident in the facility.

Inspectors wroteBased on interview and record review the facility failed to notify the doctor for the treatment of a laceration (a deep cut or tear in skin or flesh) to the upper lip for one of four sampled residents (Resident 1). This deficient practice placed Resident 1 at risk for infection and pain on the upper lip.

Inspectors wroteBased on interview and record review the facility failed to create a resident centered care plan for one of four sampled residents (Resident 1) when Resident 2 hit Resident 1 and Resident 1 sustained a laceration (a deep cut or tear in skin or flesh) to the upper lip. This deficient practice placed Resident 1 at risk for pain and infection of the laceration on the upper lip.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the facility ' s activities program was directed by a certified Activities Director since 6/13/2023 in accordance with the facility policy. This failure had the potential to not be able to provide an activity program based on Residents ' needs, which can affect the residents ' quality of life.