Pico Rivera Healthcare Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food safety practices and sanitary food storage and food preparation practices when the facility failed to:1. Maintain cold food items at safe temperatures when broccoli salads measured 66 to 68 degrees Fahrenheit ( F, a scale of temperature).2. Ensure bowls of yogurt were properly immersed in an ice bath or stored to maintain acceptable temperatures of 40 F and below during tray line or pre-handling service.3. Ensure one box of beans and one box of lentils were adequately sealed and stored in the dry food storage area.4. Ensure one can of diced red peppers were labeled with the date received.5. Ensure food items for Resident 59 and Resident 16 were labeled with sufficient information to determine safe storage duration in the facility's resident refrigerator. [...]

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 three sampled residents (Residents 4 and 49) by failing to:1. Ensure the manufacturer label on the bottle of aspirin (a medication used to prevent heart attack [flow of blood and oxygen is blocked] and stroke [loss of blood flow to a part of the brain]) that was used to administer one tablet of aspirin from, to Resident 4 on [DATE] indicated a valid expiration date in accordance with professional standards of practice.2a. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ask one of two sampled residents' (Resident 86) preference of wearing a bib during meals. This deficient practice resulted in Resident 86's freedom of choice to wearing a bib being violated, as the resident thought it was the facility's protocol to wear a bib during meals.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents' (Resident 41) Psychiatric Progress Notes were not filed in another residents medical record. This deficient practice resulted in a violation of Resident 41's confidentiality of medical records.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 70's) Depakote ([generic name - divalproex sodium] a medication used to treat seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness] and to manage mood disorder symptoms) was prescribed and administered in accordance with the documented prescriber's evaluation, diagnosis and clinical indication for Resident 70. [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately assess and code the Minimum Data Set (MDS - a resident assessment tool) assessment for one of five sampled residents (Resident 70) by inaccurately documenting and coding the diagnosis of bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) in the MDS without receiving the diagnosis from a physician. This deficient practice had the potential for inaccurate and/or unnecessary care and treatments for bipolar disorder for Resident 70.(Cross-reference with F605)

Inspectors wroteBased on interview and record review, the facility failed to submit a Preadmission Screening and Resident Review (PASRR- a federally mandated screening process designed to ensure individuals with serious mental illnesses or intellectual/development disabilities receive the necessary support) Level 1 Screening for one of three sampled residents (Resident 47) after a significant change in Resident 47's mental condition. This deficient practice resulted in the failure of a more in-depth Level 2 Mental Health Evaluation not being conducted and had the potential for Resident 47 to not receive the necessary and appropriate psychiatric level treatment and evaluation in the facility.

Inspectors wroteBased on interview and record review, the facility failed to conduct an Interdisciplinary Team ([IDT], a coordinated group of experts from several different fields) meeting for one of two sampled residents (Resident 70) after Resident 70 had an unwitnessed fall on 3/31/2025. This deficient practice had the potential to result in inappropriate interventions implemented which could result in Resident 70 sustaining another fall.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents' (Resident 8) gastrostomy tube (g-tube- a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) feeding (specialized liquid nutrition through the g-tube) bottle was labeled with Resident 8's name and the date and time the bottle was opened. This deficient practice had the potential for Resident 8 to receive the incorrect g-tube feeding and placed Resident 8 at risk of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate respiratory monitoring, documentation, and assessments were completed, and ensure a No Smoking/Oxygen in Use sign was displayed on the outside of the entrance of a resident room where an oxygen concentrator (a medical device that provides oxygen-enriched air to help people breathe) was in use for two of eight sampled residents (Resident 98 and Resident 1).a. Complete a change of condition assessment after Resident 98 developed wheezing (a high-pitched sound made when breathing is restricted/obstructed in the lungs) and required a breathing treatment and oxygen administration.b. Document Resident 98's oxygen administration after the resident's new onset of wheezing.c. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure fluid restrictions were followed for one of eight sampled residents (Resident 67), who was receiving hemodialysis (dialysis, a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) treatment. This deficient practice had the potential to place Resident 67 at risk for fluid retention and overload.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of two inspected medication carts (West Station Medication Cart) maintained accurate documentation of a resident's (Resident 109's) tramadol (a controlled medication [medications that the use and possession of are controlled by the federal government] used to treat moderate to severe pain) on the accountability record or controlled medication count sheet/controlled drug record ([CDR] - a document indicating perpetual inventory and administration of controlled substances) after tramadol was administered, as per facility's policy and procedure (P&P) titled, Controlled Substances, dated 3/2023. This deficient practice failed to maintain accurate documentation of an administered controlled medication for Resident 109 and had the potential risk for medication errors, medication misuse, and diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure the manufacturer label on a bottle of aspirin (a medication used to prevent heart attack [flow of blood and oxygen is blocked] and stroke [loss of blood flow to a part of the brain]) that was used to administer one tablet of aspirin from, to Resident 4 on [DATE] indicated a valid expiration date, affecting one of three residents (Resident 4) observed during medication administration task.2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to offer one of two sampled residents (Resident 86) meal substitutions. This deficient practice had the potential to result in Resident 86 being hungry which could lead to weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control measures for three of five sampled residents (Residents 74, 49, and 75) when:1. Certified Nursing Assistant (CNA) 1 did not sanitize a bedside table, brought from another resident room, prior to placing and serving Resident 74's breakfast tray. 2. Licensed Vocational Nurse (LVN) 8 did not wash their hands before administering Artificial Tears eye drops (a medication used to treat dryness and itchiness in eyes) to Resident 49 during medication pass observation.3. Enhanced Barrier Precaution (EBP- an infection control measure to protect residents at high risk for multidrug-resistant organisms [MDRO- bacteria resistant to multiple classes of antibacterial medication]) signage was not displayed at Resident 75's room. [...]

Inspectors wroteBased on interview and record review, the facility to ensure the primary care provider (PCP) was notified for one of seven residents ' (Resident 1), when: 1. Resident 1 had missed doses of Macrobid oral capsule (a type of antibiotic) to treat Urinary Tract Infection ([UTI], an infection in the bladder/urinary tract) on 3/11/2025, 3/13/2025, and 3/15/2025. 2. Resident 1 refused the suprapubic catheter (a thin, flexible tube inserted directly into the bladder through a small incision in the lower abdomen above the pubic bone) changed as ordered by the PCP. These failures had the potential to cause unresolved UTI and can lead complications such as sepsis (a life-threatening infection), hospitalization, and death.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure, three of seven sampled residents (Residents 1, 6, and 7), received oxygen as per physician's orders and oxygen saturations ([O2 sat], a measurement of how much oxygen the blood is carrying as a percentage, normal range is 95-100%) were checked accurately. These failures had the potential to not identify Residents 1, 6, and 7's oxygenation status and placed the residents at risk for complications related to poor oxygenation (the process of supplying blood or tissues with oxygen) such as respiratory distress (a condition where breathing is labored and inadequate), hospitalization and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to remove the identifiable health information (any information that could be used to identify the individual, such as the full name, date of birth , etc.) on the gastrostomy tube (GT, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach, for people with swallowing problems) feeding bottle before disposing in the trash can for one of eight sampled residents (Resident 23). This deficient practice had the potential to result in unauthorized disclosure of Resident 23's personal information to unauthorized users.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a plan of care for a resident that exhibited a behavior of teeth grinding for one out of six sampled residents (Resident 4). This deficient practice had the potential to delay the care or treatment of Resident 4's teeth grinding behavior.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary respiratory care and services that were in accordance with the facility's policy for one of eight sampled residents (Resident 239), when the facility did not display No Smoking/ Oxygen in Use signs on the outside of the door of the resident room or in the room where an oxygen concentrator (a medical device that provides oxygen-enriched air to help people breathe) was at the bedside. This deficient practice had the potential to cause fire hazards to all residents, families, visitors, staff, and residents' properties, and result in serious harm and injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure it was free of a medication error rate of five percent (%) or greater, as evidenced by the identification of 6 medication errors out of 28 opportunities for error, to yield a cumulative error rate of 21.43% for one of two of sampled residents (Residents 43). Licensed Vocational Nurse (LVN) 1 administered six oral medications to Resident 43 at one time. Resident 43 had a diagnosis of dysphagia (difficulty swallowing). This deficient practice resulted in Resident 43 not being able to swallow her medications and had the potential to cause aspiration (when a fluid or solid accidentally enters the windpipe and lungs) or a choking hazard for Resident 43.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled resident (Resident 43) was assessed for swallowing ability prior to administering oral medications. This deficient practice resulted in Resident 43 not being able to swallow her medications and had the potential to cause aspiration (when a fluid or solid accidentally enters the windpipe and lungs) or a choking hazard.

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor the food preferences and offer an alternative menu for one of eight sampled residents (Resident 75). This deficient practice had the potential to impact Resident 75's nutritional status and quality of life and result in food dissatisfaction leading to insufficient food intake.

Inspectors wroteBased on observation, interview, and record review, the facility failed ensure proper infection control practices were implemented for two of six sampled residents (Resident 189 and Resident 23) when the facility failed to perform the following: 1. Ensure Resident 189, who had a fever and a productive cough, was placed on isolation precautions (methods used to prevent the spread of germs and infections in healthcare and residential settings), as indicated in the facility's policy. 2. Ensure Resident 23's nasal cannula (NC, a plastic medical device to provide additional oxygen to a person directly into the nostrils) was not touching the floor on 1/6/2025 and 1/7/2025. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the necessary care and services for one of seven sampled residents (Resident 95) by failing to: a. Notify the physician of a change of condition (COC) when Resident 95's blood sugar level (measure of glucose [sugar] in the blood [normal range 70- 100 milligrams [mg, unit of measurement] per (/) deciliter [dl, unit of measurement] mg/dl) was elevated on 11/8/2023. b. Notify the physician when Resident 95 began to experience congestion (an abnormal or excessive accumulation of a body fluid), gurgling (a hollow bubbling sound), wheezing, and an episode of emesis (vomiting) on 11/9/2023. These failures resulted in Resident 95 experiencing elevated blood sugar levels over a 24-hour period from 11/8/2023 to 11/9/2023, and respiratory distress and emesis on 11/9/2023. [...]

Inspectors wroteBased on observation, interview, and record review, the kitchen staff failed to wash their hands prior to becoming in contact with food, failed to check food temperatures, and failed to store food under sanitary conditions when the following occurred: 1. The Dietary Supervisor (DS) did not wash their hands before checking food temperatures. 2. The refrigerator stored food without a use by date. 3. The refrigerator stored food that was spoiled. 4. The freezer stored food without the date that it was placed in the freezer and did not have a use by date. 5. Food temperatures were not checked prior to serving food to residents. These deficient practices had the potential to result in the transmission of infectious agents that could lead to food borne illnesses in vulnerable residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure quality of care was provided for two of 23 sampled residents (Resident 74 and 297) when the following occurred: 1. Licensed staff failed to complete a 72-hour neurological check (a physical examination to identify signs of disorders affecting your brain, spinal cord and nerves) as ordered by the physician and as indicated within the facility's policy after Resident 297, who was admitted to the facility with a history of a fall which resulted in a subdural hemorrhage (bleeding in the area between the brain and the skull), had another fall (in the facility) with head trauma (physical injury). 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatments and services to two of seven sampled residents (Residents 27 and 82) to prevent and/or limit a decline in joint (where two bones meet) range of motion (ROM, full movement potential of a joint) and mobility (ability to move) when the facility failed to: 1. Provide ROM services for Resident 27 to improve or prevent a decline in both of Resident 27's arms. 2. Provide Restorative Nursing Aide (RNA, nursing aide program that helps residents maintain their function and mobility) ambulation (walking) exercise five times a week as ordered for Resident 82. These deficient practices had the potential to cause residents to have a decline in mobility (ability to move), lead to contractures (loss of motion of a joint), and have a decline in physical functioning such as the ability to eat, dress, and walk.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) for medication administration for six out of 10 sampled residents (Resident 28, 35, 51, 68, 81, 82) when: 1. Licensed Vocational Nurse (LVN) 4 did not administer the routine 9:00 a.m. dose of medication to Resident 28, 35, 68, 81, and 82 on [DATE]. 2. Resident 28, 35, and 81 was administered Tenormin, Diltiazem, Amlodipine, Labetalol, and Hydralazine (medications used to treat high blood pressure) despite meeting the hold parameters (when a medication is not administered based on a specific condition) for having a heart rate lower than 60. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure their medication error rate was less than five (5) percent (%) when Licensed Vocational Nurse (LVN) 4 failed to competently administer medications to three (3) of five (5) randomly selected residents (Residents 81, 74, and 7) during the medication administration observation. The outcome was 16 medication errors out of thirty opportunities for errors, which resulted in a Medication Administration Error Rate of fifty-three (53) percent, based on the following: 1. Resident 81 did not receive four (4) ordered medications that were documented as administered, and Resident 81 received one (1) medication more than one hour after the permitted administration time. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and calibrate (process that ensures the reading and functionality of a device is accurate and in full working order) the ultrasound/electrotherapy modality machine (medical device that includes both ultrasound, a method to produce high-frequency sound waves that can travel deep into tissue and create therapeutic heat and electrotherapy, a method that sends electrical pulses through the skin) for resident use in the rehabilitation department. This deficient practice had the potential to cause injury to any resident who used this equipment as part of their therapy treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff were sitting at eye-level while providing feeding assistance to one of five sampled residents (Resident 10). This failure had the potential to result in affecting Resident 10's self-esteem and self-worth.

Inspectors wroteBased on interview and record review, the facility failed to provide information and education regarding an Advance Directive (a written instruction, such as a living will or durable power of attorney for healthcare, recognized under State law, relating to the provision of healthcare when the individual is incapacitated) to one of six sampled residents' (Resident 7) Responsible Party (RP). This failure had the potential to result in Resident 7's preferences for care in an emergency, or in the event she became incapacitated (unable to participate in a meaningful way in medical decisions) or unable to make medical decisions, would not be identified and/or carried out by the facility staff.

Inspectors wroteBased on interview and record review, the facility failed to provide the Notice of Medicare Non-Coverage (NOMNC, notice indicating when Medicare [federal health insurance for people 65 or older, and some people under 65 with certain disabilities or conditions] covered services are ending) to the resident's Responsible Party (RP) two days before their Medicare covered services ended for one of three sampled residents (Resident 27). This failure had the potential to result in Resident 27's RP not having ample time to exercise their right to file an appeal.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement an individualized care plan with measurable objectives, timeframes, and interventions to improve, prevent and/or limit a decline in joint (where two bones meet) range of motion (ROM, full movement potential of a joint) for one of seven sampled residents (Resident 27) who was identified as having a decline in ROM to both arms. This deficient practice had the potential to negatively affect the delivery of necessary care and services for Resident 27 and lead to contracture (loss of motion of a joint associated with stiffness and joint deformity) development and a decline in overall physical functioning such as the ability to move, eat and dress.

Inspectors wroteBased on interview and record review, the facility failed to revise the resident-centered care plan (document that helps nurses and other team care members organize aspect of resident care) for one of six sampled residents (Resident 74) who had a change in her ability to carry out her activities of daily living (ADLs, term used to collectively describe fundamental skills required to independently care for oneself, such as eating, bathing, and mobility). This failure had the potential to result in Resident 74's needs not be met due to the staff being unaware of the required assistance needed.

Inspectors wroteBased on interview and record review, the facility failed to ensure Registered Nurse (RN) 3 received report (oral communication between care providers to describe that status of the resident) for one of three sampled residents (Resident 74) who was readmitted to the facility from the general acute care hospital (GACH). This failure resulted in the nursing staff and physician being unaware of Resident 74's computed tomography (CT, imaging that helps detect internal injuries and diseases) scan results that showed a compression fracture (type of broken bone that can cause the vertebra [bone in the spine] to collapse) of the second lumbar vertebrae (L2, bone in the lower end of the spinal column).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff provided the necessary care and services to two sampled residents (Resident 85 and 35) when: 1. Certified Nursing Assistant (CNA) 2 failed to report Resident 85's change in condition to a licensed nurse. 2. CNA 2 failed to properly reposition Resident 85 in bed. 3. Staff did not reposition Resident 35 and Resident 85 every 2 hours. These deficient practices had the potential for Resident 85's health changes to become compromised and go unnoticed, and had the potential to result in skin breakdown or compromised skin integrity for Resident 35 and Resident 83.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure precautions were maintained to prevent the development of pressure ulcers (PU, an injury that breaks down the skin and underlying tissue, caused when an area of skin is placed under prolonged pressure) for one of five sampled residents (Resident 73) by failing to: 1. Ensure Resident 73's weight was accurately set on the low air loss mattress (LALM, a mattress designed to distribute body weight over a broad surface area to help prevent skin breakdown). These failures had the potential to result in the development of skin breakdown and/or pressure ulcers which could result in complications associated with impaired skin integrity for Residents 73.

Inspectors wroteBased on interview and record review, the facility failed to ensure fall precautions were maintained for two of five sampled residents (Resident 22 and Resident 73) when the following occurred: 1. Resident 22 did not have fall mats placed at her bedside, and call light was not within her reach. 2. Resident 73 did not have a fall mat placed at her bedside. These failures had the potential to cause avoidable harm to Resident 22 and Resident 73 related to repeat falls and the potential injuries related to sustaining a fall.

Inspectors wroteThe facility failed to ensure the resident's nasal cannula (device used to deliver supplemental oxygen or increased airflow through the nose) and the oxygen concentrator humidifier bottle (medical devise that increases the humidity in the nostrils while using supplemental oxygen) were labeled with the date, time, and initials of the nurse when initially used for Resident 10 and Resident 51. This deficient practice had the potential to cause a negative respiratory outcome and increased the risk for Resident 10 and Resident 51 to acquire a respiratory infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident who received dialysis (the process of removing waste products and excess fluid from the body using a machine when the kidneys are not able to do so) treatment was assessed before and after dialysis treatment and the assessment was documented in the Dialysis Communication Records for one of one sampled resident (Resident 81). This deficient practice had the potential for unidentified complications after dialysis treatment such as swelling, pain, bleeding, and bruising.

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform a competency assessment for Licensed Vocational Nurse (LVN) 4 upon hire as per the facility's policy and procedure (P&P), which resulted in LVN 4 failing to competently administer medications and supplements as ordered by the physician for three out of five sampled residents (Resident 81, 74, and 7), including one significant medication administration error, during the medication administration observations. This deficient practice had the potential to place Resident 81, 74, and 7, and other residents at risk for harm related to improper administration of medication, and delays in provision of care related to missed administrations of ordered medications and supplements. Cross Reference:

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 74) was free of significant medication errors by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 4 did not administer 10 units (a unit of measurement for insulin) of Lantus (insulin glargine, a medication used to control blood sugar levels) when resident 74's blood sugar was outside of the holding parameters (specific instructions for when and when not to administer a medication based on measurable values). 2. Ensure Licensed staff did not document administration of thirty-seven (37) of Lidocaine 5% patches (medicated patch applied to the skin for pain management) for Resident 74, when only fourteen (14) patches had been dispensed to the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain the results for one of two sampled residents (Resident 74) computed tomography (CT, imaging that helps detect internal injuries and diseases) scan in a timely manner when Resident 74 was readmitted to the facility from the general acute care hospital (GACH). This failure resulted in Resident 74's physician being notified two weeks after the CT scan was completed with results that indicated a compression fracture (type of broken bone that can cause the vertebra [bone in the spine] to collapse) of the second lumbar vertebrae (L2, bone in the lower end of the spinal column).

Inspectors wroteBased on interview and record review, the facility failed to ensure three of three sampled residents (Resident 41, 74, and 82) understood the Arbitration Agreement (an agreement between the facility and the resident where they would resolve any disputes through a neutral person rather than going to court) when entering a binding contract by failing to: 1. Present the Arbitration Agreement in a language Resident 82 understood. 2. Ensure Resident 82, Resident 41's Family Member (FM) 1, and Resident 74's Family Member (FM) 2 understood that signing the Arbitration Agreement was not necessary as a condition of admission to the facility. These failures resulted in Resident 82 not understanding in the language he understood and Residents 41, 74, and 82 entering the binding agreement as a pretense that it was mandatory.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement effective infection prevention measures for three of seven sampled residents (Resident 2, 10, and 46) when the facility failed to: 1. Post signage in and around Resident 2's room to ensure staff providing direct resident care activities were aware of Resident 2's Enhanced Standard Precautions (ESP, infection control intervention using gown and gloves during high contact resident care activities designed to reduce the transmission of multi-drug resistant organisms). 2. Ensure the Treatment Nurse (TN) performed hand hygiene (a way of cleaning one's hands that substantially reduces the potential germs on the hands) throughout Resident 46's wound treatment. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a call light that was maintained in proper working condition and without a frayed cord with inner wires exposed for one out of 24 sampled residents (Resident 69). This deficient practice resulted in Resident 69 using an unsafe call light and the potential to not have needs met.