Plaza Healthcare Center

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of five residents (Resident 1) was free from abuse. * The facility failed to ensure Resident 1 was free from abuse by Resident 2 when Resident 2 struck Resident 1 on the left forearm with a wooden back scratcher. This failure placed the resident at risk for further abuse.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of six sampled residents (Resident 1) was protected from sexual abuse. * On 5/30/26, Resident 2 was found on top of Resident 1, in Resident 1's room. Residents 1 and 2 were face to face in bed and Resident 2 was observed humping on top of Resident 1. Resident 1 lacked the cognitive capacity to provide informed consent or make reasonable decisions regarding personal safety. Considering Resident 1's cognitive ability, a reasonable person would consider this as severe emotional trauma and may go through post traumatic issues, violation of personal rights, and potential physical injury due to the unsafe positioning of Resident 2 on top of Resident 1. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to fully inform the resident or resident's responsible party and obtain a completed informed consent prior to the use of the psychotropic medications for two of four sampled residents (Residents 1 and 4) reviewed for unnecessary psychotropic medications. * The facility failed to ensure the informed consent was obtained from Resident 1 or the resident's representative before administering the buspirone hydrochloride (antianxiety medication) medication to Resident 1. * The facility failed to ensure the informed consent was obtained from Resident 4 or the resident's representative before administering the Clozaril (atypical antipsychotic medication) and Depakote (mood stabilizer medication) medications to Resident 4. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of six sampled residents (Resident 4) reviewed for abuse was free from abuse. * The facility failed to protect Resident 4's right to be free from physical abuse by another resident (Resident 5). Resident 4's right foot was punched twice by Resident 5. Resident 4 had two right dorsal (top) foot superficial scratches. This failure had the potential for Resident 4 to be seriously injured or have negative psychosocial outcomes.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to report an abuse allegation to CDPH, L&C Program for one of six residents (Resident 4) reviewed for abuse. * The facility failed to ensure SOC 341 was sent to CDPH, L&C Program. The facility faxed the SOC 341 form for Resident 4's abuse allegation to CDPH, L&C Program's phone number, instead of CDPH, L&C Program's fax number. This failure had the potential for the abuse allegation going unreported and uninvestigated.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive care plan was revised for one of eight sampled residents (Resident 5). * The facility failed to ensure Resident 5's comprehensive care plan was revised to reflect the resident's inappropriate behaviors toward staff when ADL care was provided. This failure placed the resident at risk of not being provided with the appropriate interventions and individualized care.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the medical record was accurate and complete for one of four sampled residents (Resident 3). * Resident 3's assessments for the bed rails, bowel and bladder, elopement, falls, lift and transfer, self-administration of medications, smoking, vital signs and pain, Braden (skin assessment and risk factors), GG (section in the MDS (a standardized assessment tool) to address the residents functional abilities) were not completed quarterly. These failures had the potential for negative effects and had the potential to not receive the appropriate care and services.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to provide the reasonable accommodations to meet the care needs for three of three sampled residents (Residents 9, 10, and 11) observed for call lights. * The facility failed to ensure Resident 9 had a urinal to use when he needed to urinate. In addition, the facility failed to respond timely when Resident 9 pressed his call light to ask for assistance which resulted in Resident 9 soiling his pull ups. * The facility failed to ensure the call light was within Resident 10 and 11's reach. These failures posed a risk for residents' care needs not being met and could negatively impact the residents' health and well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the resident was free from unnecessary psychotropic medication for one of four residents (Resident 4) reviewed for the psychotropic medication use. * The facility failed to ensure Resident 4 had the mental capacity to give consent for the administration of the clonazepam (anti-anxiety) medication. In addition, the facility failed to ensure the lorazepam informed consent included the reason and duration for Resident 4's use of lorazepam (anti-anxiety) medication and the Surrogate IDT Proposal of Medical Intervention was completed. These failures had the potential for the resident to have adverse effects from the psychotropic medications.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the sanitary/safe conditions, and food services were maintained as evidenced by: * The facility failed to ensure the bag of pepperoni slices and pizza crust were dated and the expired gallon of milk was removed from the storage area. * The facility failed to ensure there was no leak under the sink and water was not pooling on the floor near the trayline area and stove. * The facility failed to ensure [NAME] 1performed hand hygiene after picking up a food item from the floor and before touching a clean utensil. * The facility failed to ensure the staff wore or properly wore the hair restraint while inside the kitchen, These failures posed the risk of food borne illness to the residents receiving food from the kitchen.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the residents' meal was served according to their diet order for all the residents receiving meal from the kitchen as per the facility P&P. * The facility failed to ensure prior to serving the meal trays, the licensed nurse checked the foods served to the residents were according to the physician's order. This failure posed the risk for the residents to not receive the correct diet as ordered by the residents' physicians.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure sufficient fluids was provided for two of three sampled residents (Residents 9 and 10) observed for hydration. * The facility failed to ensure Resident 10 had a water pitcher inside her room. * The facility failed to ensure Resident 9's water pitcher was refilled with water. These failures posed the risk for the residents to not receive an appropriate hydration.

Inspectors wroteBased on interview and facility document review, the facility failed to ensure the facility assessment showed a resident centered staffing plan to meet the needs of the residents. * The facility failed to ensure the assessment specified the staff members' competencies to care for residents with psychiatric disorders. This failure posed the risk for staff members not being able to provide the appropriate care when the residents had escalating behavior episodes.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the kitchen utensils were clean and free of food particles or residue. * The facility failed to ensure the kitchen utensils had a smooth cleanable surface and in good condition. * The facility failed to ensure the heavy-duty blenders used for puree preparation, the clear plastic bucket containers used for the juices on the tray line and food storage were air dried prior to storing and stacking and to ensure the blender was air dried prior to puree preparation. * The facility failed to ensure the cutting boards were kept in a sanitary condition and with cleanable surface. * The facility failed to ensure the sanitary condition of the hood over the stove was maintained. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to obtain the informed consent prior to administering the psychotropic medications for one of five final sampled residents (Resident 14) reviewed for unnecessary medications. This failure had the potential for the resident not being able to make an informed decision about their treatment plan.

Inspectors wroteBased on observation, interview, medical record review, facility record review, and facility P&P review, the facility failed to protect the resident's rights to be free from the physical abuse by a resident for one of four final sampled residents (Resident 117) investigated for abuse. * Resident 117 was hit on the right eyebrow by another resident (Resident 113), resulting in a superficial skin tear. In addition, the facility failed to monitor Resident 113 as per facility's abuse protocol after a resident to resident physical altercation. These failures had the potential for not protecting the resident and negatively impact the resident's well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to report an abuse allegation to CDPH, L&C Program and Ombudsman for one of four residents (Resident 82) reviewed for abuse as evidence by: * The facility failed to report Resident 82's allegation of feeling harassed and threatened by Resident 15. This failure of not reporting abuse allegation put the resident at risk for further abuse.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to follow their protocol for written notification of transfer or discharge for four of four final sampled residents reviewed for hospitalization (Residents 10, 15, 86, and 122), one of three residents (Resident 117) reviewed for closed records, and one of three residents (final sampled resident, Resident 122) reviewed for hospice and end of life. * Resident 137's medical record did not show the resident received a discharge summary and a recapitulation of their stay when they discharged to the community. * Resident 10's Notice of Proposed Transfer and Discharge form was not completed for three acute care transfers, and the resident's record failed to show the Ombudsman was notified of the resident's acute care transfer for one of two completed Notice of Proposed Transfer and Discharge forms. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one final sampled resident (Resident 45) reviewed for ADL care was provided with the necessary care and services to maintain their ADL capabilities. * The facility failed to ensure care and services was provided to maintain good grooming and personal hygiene when Resident 45's fingernails were left dirty and untrimmed. This failure had the potential to result in injuries from scratching and spread of germs when eating.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the orthostatic hypotension was accurately monitored for one of 26 final sampled (Resident 74). This failure had the potential to not provide the necessary care for the resident monitored for orthostatic hypotension.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to complete the post-fall neurological assessments for 72 hours for two of five final sampled residents reviewed for accidents (Residents 10 and 47). This failure had the potential for a delay in identifying and intervening with neurological changes.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to administer G-tube enteral feeding formula administration for one of two final sampled residents reviewed for tube feeding (Resident 12). This failure had the potential for the resident to have undesirable outcomes, including aspiration.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care and services for two of 26 final sampled residents (Residents 22 and 63) reviewed for oxygen therapy. * The facility failed to ensure Resident 22's nasal cannula tubing was dated and labeled as per the facility's P&P. In addition, the facility failed to ensure the nasal cannula tubing was stored in a set-up bag when not in use for Resident 22. * The facility failed to ensure Resident 63's respiratory changes were identified timely and care planned. These failures had the potential for the residents to not receive the appropriate care and may negatively impact the residents' medical conditions.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed follow their pain protocol and physician's orders for one of two final sampled residents (Resident 47) reviewed for pain. * Resident 47's order for hydrocodone-acetaminophen (a controlled pain medication) to be administered prior to therapy (PT/OT) was administered daily at 0800 hours, regardless of the resident's actual therapy time, including on days no therapy was received. * Resident 47 had two PRN medications orders for pain without pain level parameters. * Resident 47's MAR showed the resident was administered PRN pain medications for a pain level of zero. These failure resulted in the resident receiving unnecessary pain medication as well as putting the resident at risk for pain during therapy services.

Inspectors wroteBased on interview, medical record review, facility P&P review, and facility document review, the facility failed to ensure the orders for NPO were followed and the Pre and Post Dialysis Assessment forms were completed for one of one final sampled resident investigated for dialysis (Resident 33). This failure had the potential of not identifying potential negative outcomes for the dialysis residents.

Inspectors wroteBased on observation, interview, facility P&P review, and facility document review, the facility failed to ensure to follow the puree recipe for puree vegetables for 21 residents on puree diet. This failure posed the risk of the residents not receiving food prepared by methods that conserve nutritive value.

Inspectors wrote3. Review of the facility's P&P titled Hand Hygiene revised 9/1/20, showed hand hygiene is the primary means to prevent the spread of infections. Hand hygiene should be performed before donning and after doffing personal protective equipment, immediately upon entering, and exiting a resident's room. On 6/11/25 at 0819 hours, a medication administration observation for Resident 39 was conducted with LVN 5. LVN 5 was observed checking Resident 39's BP at his bedside. LVN 5 then left the resident's room and went to the medication cart just outside the resident's doorway. LVN 5 donned gloves, used disinfectant wipes to clean the BP equipment, removed the gloves, wrote the BP results on a pad of paper using a pen, retrieved the resident's medication and placed it in a small medication cup and brought the medication to the resident in his room. [...]

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to provide the reasonable accommodation to meet the needs of two final sampled residents (Residents 45 and 63) reviewed for accommodation of needs. * The facility failed to ensure the call lights for Residents 45 and 63 were kept within the residents' reach. This failure had the potential for the residents' care needs not being met.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the pharmaceutical services to ensure accurate reconciliation of the controlled medication for one of 26 final sampled residents (Resident 82). Resident 82's hydrocodone (a controlled medication for pain) controlled medication count sheet was not maintained accurately for medication reconciliation. This failure posed the risk for diversion of controlled medications.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the garbage was properly stored in two of three garbage dumpsters. This failure had the potential to attract pest/rodents that carried diseases.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one final sampled resident (Residents 22) had the accurate and complete medical record. * The facility failed to ensure Resident 22's meal intakes were accurately documented. This failure had the potential for the resident's health care needs to not be met as the medical record was incomplete and inaccurate.

Inspectors wroteBased on observation, interview, medical record review, facility P&P review, and facility document review, the facility failed to ensure one of three final sampled residents (Resident 22) reviewed for pressure injury was provided the necessary care and services when the LAL mattress was set incorrectly for Resident 22. In addition, Resident 22 was left lying on multiple layers of bedding, absorbent pad, and an incontinent brief. These failures had the potential for the resident not to receive the appropriate care and services to promote skin healing.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent further falls and/or injuries for two of four sampled residents (Residents 3 and 7). * The facility failed to ensure Resident 3's post fall neurological assessment and monitoring were completed. Additionally, Resident 3's attending physician and responsible party were not notified after the resident had sustained a fall on 4/15/25. * Thefacility failed to provide the necessary care and services Resident 7 post fall sustaining injury and documented abnormal findings from neurological assessment. In addition, Resident 7's post fall assessment was not completed accurately. These failures posed the risk of the residents to not receive timely interventions to address their post fall status.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of four sampled residents' (Resident 1) medical record was accurate and complete. * The facility failed to ensure there was nursing documentation for 72 hours each shift for a COC. This failure posed the risk for changes in Resident 1's health condition to go undetected and possibly delay necessary care and treatment.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the weekly skin checks were completed and documented in the medical record as per the facility's P&P for one of two sampled residents (Resident 8). This failure had the potential for the resident's care needs not being met as their medical information was inaccurate.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the necessary pharmacy services were provided to one of three sampled residents (Residents 1). * The facility failed to ensure the Geodon medication administered to Resident 1 was not from another resident's Geodon medication vial. In addition, the facility failed to ensure the discontinued Geodon medication was kept in the designated area to be disposed. These failures had the potential to cause unsafe administration and handling/storage of the residents' medications.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of three final sampled residents (Resident 1) was properly monitored as evidenced by: * The facility failed to ensure the order for Resident 1's Geodon (antipsychotic medication) was transcribed and documented after obtaining the verbal order from the NP. * The facility failed to ensure the consent for the use of Geodon medication was obtained from Resident 1's conservator. * The facility failed to ensure the administration of the Geodon medication and the side effects monitoring were documented in Resident 1's MAR. * The facility failed to ensure a care plan was initiated to address Resident 1's Geodon medication use. These failures had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on interview, observation, medical record review, and facility P&P review, the facility failed to provide the necessary interventions and services for two of four sampled residents (Residents 1 and 2) to prevent further decline in their ROM functions. This failure posed the risk of the decline to the residents' ROM functions.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the staff wore the appropriate PPE when providing care for one nonsampled resident (Resident A) with Covid 19. This failure posed the residents at risk for the spread of infection.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure safeguarding of the controlled medications for Residents 3, 4, 5, and 6. This failure posed the risk for the diversion of the controlled medications.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitation guidelines as evidenced by: * The facility failed to ensure the hamburgers served on 7/20/24, were well cooked for Residents 1, 2, 3, 4, A, and B. * The kitchen staff failed to wear the beard restraint while working in the kitchen. These failures had the potential risk of foodborne illness to residents, staff, and visitors who consumed hamburgers prepared in the kitchen.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the menu was followed. * [NAME] 1 failed to follow the recipe for the preparation of Potato Medley. This failure had the potential for the residents who received food prepared in the kitchen to not have their nutritional needs met.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and visitors. * The facility failed to ensure the subcutaneous syringe was properly disposed in the sharps container disposal bin. This failure posed a risk safety to residents, staff, and visitors' safety.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to promote the wound healing for two of two sampled residents (Residents 1 and 2). * The facility failed to ensure the physician's order for wound care was followed for Resident 1's Stage 4 pressure injury. * The facility failed to ensure Resident 1 who had a Stage 4 pressure injury to the sacral coccyx area was repositioned while in bed to promote the wound healing. * The facility failed to carry out the physician's wound care order written by the wound care physician for Resident 2's pressure u injury. These failures posed the risk for complications and delayed wound healing.

Inspectors wroteBased on interview, medical record review, observation, facility document review, and facility P&P review, the facility failed to protect the resident's rights to be free from the physical abuse by another resident for one of seven sampled residents (Resident 7). * Resident 7 was hit by Resident 8 causing a laceration to her left outer eye and a skin tear to her right elbow. This failure had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the implementation of their P&P for abuse prevention program for two of seven sampled residents (Residents 4 and 9) when CNA 4 received a report of physical abuse from Resident 9 regarding CNA 5 hitting Resident 4. CNA 4 took CNA 5 to see Residents 4 and 9 to identify the alleged staff. This failure created the potential for not protecting the residents from the alleged staff.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the food preference was honored for one to two sampled residents (Resident 1). * Resident 1 was served Brussel sprouts and squash; however, the resident's dietary profile assessment showed Resident 1 disliked green vegetables. This failure had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to protect Resident 1's rights to be free from the physical abuse by Resident 2. This failure had the potential to result in the serious injury and/or psychosocial harm to Resident 1.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to provide a homelike environment for one of 21 sampled residents (Resident 20). * Resident 20's room (Room A) had a hole on the dry wall, exposed drywall, and multiple areas of dark stains on the walls. * Room A's restroom had a crack behind the sink, large unpainted area above the sink, crack on the door connecting the restroom to the adjacent room and dark stains on the floor and walls near the toilet. These failures had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on interview, medical record review, and facility document review, the facility failed to ensure one of 21sampled residents (Resident 18) was free from the physical abuse when Resident 19 hit Resident 18 with an open hands. This failure had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure one of 21 sampled residents (Resident 13) attained and maintained their highest practicable well-being. * The facility failed to ensure Resident 13 was assessed and offered the pain medication as per the physician's order after complaining of the severe left knee pain. This failure posed the risk of not providing appropriate and consistent care to Resident 13.

Inspectors wroteBased on observation, interview, medical record review, and facility record review, the facility failed to ensure one of 21 final sampled residents (Resident 10) remained free from the accident hazards. * The facility failed to provide the bilateralfloor mats as per the physician's order for Resident 10. This failure had the potential to place the resident at risk for serious injury.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services to meet the needs of two of 21 sampled residents (Residents 8 and 9). * The facility failed to administer citalopram hydrobromide (antidepressant medication) to Resident 8 as ordered by the physician. * The facility failed to administer Austedo XR (medication used to treat tardive dyskinesia) to Resident 9 as ordered by the physician. These failures had the potential to negatively affects the residents' well-being.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the medications were safely stored. * The facility failed to ensure Medication Cart A was locked when left unattended. This failure had the potential for unauthorized person to have access to the medications and drug diversion in the facility.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the heavy-duty blender used for puree preparation was air dried prior to use. * The facility failed to ensure the kitchen utensils had a smooth cleanable surface and were in good conditions. * The facility failed to ensure the kitchen utensils were clean and free of food particle or residue. * The facility failed to ensure the sanitary condition of the hood over the stove was maintained. These failures had the potential to cause foodborne illnesses for the residents in the facility.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to implement their infection control surveillance program in accordance with the facility's P&P. * The facility failed to implement their infection control surveillance program from February 2024 through April 2024. The IP was unable to show documentation for the facility's monthly resident infection surveillance from of February 2024 through April 2024. The IP stated she did not complete the facility mapping of resident infections nor did she complete the Infection Control Monthly Summary Report from February 2024 through April 2024. Additionally, the facility conducted surveillance of resident infections based on whether the residents were prescribed antimicrobial medications. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility document review, the facility failed to provide the shower as per the resident's request for one of three final sampled residents (Resident 87). This failure had the potential for the resident's need to not be met promptly.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to follow up on the grievance for four of six nonsampled residents (Residents 6, 60, 77, 80, 94, and 123). This failure had the potential for the residents to not be fully informed about the resolution to the grievances.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the physician was informed of a change of condition for one or three final sampled residents reviewed for weight loss (Resident 332). The facility failed to notify the physician of Resident 332's six-pound weight loss. This failure had the potential for Resident 332 to have a delay in care and treatment.

Inspectors wroteBased on observation and interview, the facility failed to maintain a clean and homelike environment for two of 27 final sampled residents (Residents 8 and 115) and six nonsampled residents (Residents 9, 26, 30, 582, 22, and 94) reviewed for environment. * Resident 9 resided in Room D. Room D was observed with several unpainted patched areas on the walls throughout the room. * Residents 26 and 582 were roommates who resided in Room B. Room B was observed with bed linens and beverage cups on the floor. The residents' trash can was observed overflowing with trash. The room walls were observed with several unpainted patched areas. * Residents 8 and 30 were roommates who resident in Room C. Room C was observed with cereal lying on the floor adjacent to Resident 30's bed. * Residents 22 and 94 resided together in Room A. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to develop/implement the comprehensive plans of care to reflect the individual care needs for three of 27 final sampled residents (Residents 23, 69, and 115) and one nonsampled resident (Resident 29) reviewed for care plans. * The facility failed to develop the comprehensive person-centered care plan to address the use of PICC (peripherally inserted central catheter- intravenous access used for a prolonged period of time) line for Resident 115. * The facility failed to implement care plan interventions per Resident 29's plan of care addressing Resident 29's swallowing problem. * The facility failed to develop a care plan to address Resident 69's pain and use of bed rails. * The facility failed to ensure a care plan was developed to address Resident 23's need for one-to-one supervision. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility document review, the facility failed to provide the necessary care and services to ensure one of four final sampled residents (Resident 71) attained and maintained their highest practical well-being. * The facility failed to ensure Resident 71's right leg fracture with the immobilizer was assessed and monitored. This failure had the potential for the resident to not receive appropriate care and treatment.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure two of two final sampled residents (Residents 32 and 41) and one nonsampled resident (Resident 582) remained free from accident hazards. * The facility failed to implement the floor mats as per the physician's order for Residents 582, 32, and 41. This failure had the potential to place the residents at risk for serious injury.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure one of one final sampled resident reviewed for GT care (Resident 23) received the appropriate GT care. This failure posed the risk of the resident's GT not being kept patent.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the IV access for one of one final sampled resident reviewed for IV therapy(Resident 115). * The facility failed to ensure the PICC (peripherally inserted central catheter- intravenous access used for a prolonged period of time) line external catheter and arm circumference measurements were completed and documented in the medical record for Resident 115. This failure had the potential to delay the identification of catheter related complications for the residents. * The facility failed to label Resident 115's IV medication tubing with the date and time when it was hung. This failure posed the potential risk for infection or phlebitis (inflammation of a vein) for Resident 115.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the oxygen therapy equipment was stored in a sanitary manner for two of three final sampled residents reviewed for respiratory care (Residents 8 and 36). * The facility failed to ensure Resident 8's nasal cannula and oxygen mask were stored in a sanitary manner. * The facility failed to ensure the administration of oxygen therapy had a physician's order, and the care plan for respiratory problem was updated for the use of oxygen for Resident 36. In addition, the oxygen tubing was labeled and not in the floor for Resident 36. These failures posed the risk for equipment contamination and associated respiratory complications.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to offer or provide adequate and appropriate pain management for one of two final sampled residents reviewed for pain (Resident 69). This failure had the potential to cause the resident unnecessary pain and complications from worsened pain.

Inspectors wroteBased on observations, interview, medical record review, and facility P&P review, the facility failed to ensure the proper monitoring, documentation, initiation of a plan of care addressing the dialysis site, and reporting to the physician of the weight variances for one of two final sampled residents reviewed for dialysis services (Resident 49). These failures had the potential to delay identifying and responding to dialysis access site issues, and delay of care and treatment for Resident 49.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to obtain a physician's order and an informed consents prior to the use of elevated side rails for one of one final sampled resident (Resident 69) and one nonsampled resident (Resident 582) reviewed for use of bed rails. This failure had the potential to put the residents at risk for serious injuries.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the individualized behavioral health care needs and services for one of one final sampled resident reviewed for behavioral management (Resident 23) were met. * Resident 23 was diagnosed with schizophrenia (a severe brain disorder in which people interpret reality abnormally) with a thorough clinical assessment and was prescribed a risperidone (antipsychotic medication). However, the facility failed to ensure a physician's order was obtained for one-to-one supervision and the IDT or Bioethics Committee meeting was conducted where a possible psychotropic medications and behavior management of Resident 23 were discussed and recorded. This failure had the potential for the resident not able to attain the highest practicable wellbeing.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the pharmacy services were provided as evidenced by: * The medications for two of two final sampled residents (Residents 6 and 23) and two nonsampled residents (Residents 77 and 80) reviewed for medication administration were not acquired in a timely manner. This failure had the potential for the residents to not consistently receive their medications as ordered. *The staff's personal items were stored inside a medication room. This failure posed the risk of not keeping an accurate account of medications stored inside the medication room.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure seven out of seven final sampled residents reviewed for unnecessary psychotropic drugs (Residents 23, 36, 49, 105, 112, 124, and 332) were free from unnecessary psychotropic drugs (any drug that affects brain activity associated with mental process and behavior). * The facility failed to ensure Resident 49's monitoring for orthostatic blood pressure (blood pressure obtained when sitting or lying down, and after standing; used when monitoring for potential side effects from antipsychotropic use), for the use of clozapine (antipsychotic) and aripiprazole (antipsychotic) was accurate. * The facility failed to ensure Resident 332's monitoring of orthostatic blood pressure, for the use of quetiapine fumarate (antipsychotic) was accurate. [...]

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the medication error rate was lower than five percent. This failure posed the risk of the residents not receiving appropriate care.

Inspectors wroteBased on observation, interview and medical record review, the facility failed to ensure one nonsampled resident (Resident 29) received the appropriate mechanically altered diet (the texture of the diet is altered) as ordered by the physician. This failure had the potential for the resident to choke and/or aspirate (inhalation of foreign object into the airway and/or lungs).

Inspectors wroteBased on observation and interview, the facility failed to ensure one of two medication rooms' refrigerator freezer compartment was free of ice buildup. This failure posed the risk of the medication room refrigerator not maintained in safe operating temperature and condition.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the resident's bed was inspected and with the record of the bed inspection when identifying areas of possible entrapment with the use of bed rails for one of two final sampled residents reviewed for bed siderail use (Resident 69). This failure had the potential to negatively impact the residents for possible entrapment, serious injury, and death.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the written information regarding the advance directive and/or obtain and maintain copies of the advance directives in the medical records for two of three final sampled residents (Residents 49 and 123). These failures had the potential for confusion or failure to provide care and life sustaining measures in accordance with the residents' treatment wishes.

Inspectors wroteBased on observation and interview, the facility failed to ensure the residents' medical records were kept secure and confidential. This failure posed the risk of unauthorized personnel having access to the residents' medical records and also not maintaining the medical records intact.

Inspectors wroteBased on interview and facility document review, the facility failed to ensure the performance evaluations were completed every 12 months for two of three CNA employee's files reviewed (CNAs 6 and 7). This resulted in the CNA's not being provided with the appropriate training or in-service education based on their performance review, which had the potential to negatively impact resident care.

Inspectors wroteBased on observation and interview, the facility failed to ensure the medications for Resident 48 stored inside an IV medication cart were kept locked. This failure posed the risk of unauthorized persons having access to the medications stored inside the IV medication cart.

Inspectors wroteBased on observation and interview, the facility failed to ensure the garbage was properly stored in two of four garbage dumpsters. The failure had the potential to attract pests/rodents that carried diseases.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the medical record was accurately maintained for one of 27 final sampled residents (Resident 104). *Resident 104's POLST failed to show documentation as to whether Resident 104 had formulated an Advance Directive. This failure had the potential for the resident's care needs not being met as the medical record was incomplete.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the physician was notified when one of seven sampled residents (Resident 1) refused to take the antipsychotic medications (medication use to treat psychosis) as ordered. This failure had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure lunch was provided at the facility's established mealtime. This failure had the potential for not meeting the residents' needs.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to store trash in a sanitary manner as evidenced by: * The facility failed to ensure two of four dumpsters were properly covered. This failure had the potential to harbor pests.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of two sampled residents (Resident 1) was free from the physical restraints. * The facility utilized a seat belt on Resident 1 while she was sitting in a wheelchair. The facility failed to complete the comprehensive assessment, obtain the informed consent prior to applying the seat belt, determine the least restrictive interventions before the seat belt was utilized, and develop and implement the interventions to prevent and address any risks related to the use of the seat belt. These failures had the potential for increased risk of physical harm to the resident.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to promote dignity and respect for three of seven sampled residents (Residents 5, 6, and 7) and three nonsampledresidents (Residents A, B, and C). * The facility failed to ensure the call lights were answered in a timely manner for Residents 5, 6, 7, A, B, and C. * The facility failed to ensure the hair cut was provided for Residents 5 and B. These failures posed the risk to negatively affect the residents' physical and emotional well-being.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the medical record for one of seven sampled residents (Residents 7) were complete. * The facility failed to ensure the ADL flowsheetswere complete and accurate for Residents 7. This failure had the potential for the resident to not receive the appropriate care due to incomplete and inaccurate documentation in resident'smedical record.

Inspectors wroteBased on observation and interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases and infections. * The facility failed to ensure the clean linen cart was stored separately and not touching the dirty linen trolley. This failure increased the risk for the spread of infection and cross contamination of harmful microorganism.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the copy of the resident's medical record was provided upon request within two working days as per the facility's P&P for one of eight sampled residents (Resident 2). This failure had the potential for violating Resident 2 and their representative rights to access their medical health information.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the nursing staff completed the 72-hour neurological checks as per the order and facility P&P for one of eight final sampled residents (Resident 1). This failure posed the risk for changes in Resident 1's health condition not being identified, delay in necessary care and treatment, and negative health outcomes to Resident 1.

Inspectors wroteBased on interview and medical record review, the facility failed to protect Resident 1's rights to be free from physical abuse by Resident 2. Resident 2 struck Resident 1 in the face, and Resident 1 fought back and sustained a skin abrasion to his forearm. This failure had the potential to negatively affect Resident 1's psychological and physical well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility document review, the facility failed to ensure the food for one of five sampled residents (Resident 4) was consistent with the resident's need and preference. This failure had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to keep the resident's bathroom in Room B clean and in a sanitary condition. This failure had the potential to pose risk of affecting the residents' health risk.

Inspectors wroteBased on observation, interview, medical record review, and facility document review, the facility failed to protect two of 11 sampled residents' (Residents 4 and 9) rights to be free from the physical abuse by other residents (Residents 10 and 11). This failure posed the risk for injuries and psychological harm for Residents 4 and 9.

Inspectors wroteBased on interview, medical record review, and facility document review, the facility failed to implement their P&Ps to ensure the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when the allegations of abuse were not reported to the CDPH, L&C program and other agencies in a timely manner for two sampled residents (Resident 4 and 7). * The facility failed to ensure the staff reported Resident 7's allegation of being hit in the face by Resident 8 in a timely manner. * The facility failed to ensure the staff reported an incident involving Resident 11 exposing his genitalia to Resident 4 in a timely manner. These failures had the potential of placing the residents at risk for abuse and delayed conducting an investigation to determine the cause and rule out abuse.

Inspectors wroteBased on interview, medical record review, and facility document review, the facility failed to provide the necessary care and services to ensure three of 11 sampled residents (Residents 2, 7, and 11) maintained their highest practicable physical well-being. * The facility failed to ensure Resident 2's clozapine (an antipsychotic medication that treats medical health condition like schizophrenia, a severe brain disorder in which people interpret reality abnormally) medication was administered as prescribed by the physician. In addition, the facility failed to send a request to the pharmacy to refill the clozapine medication for Resident 2. * The facility failed to assess Resident 7 every shift for 72 hours after an alleged resident to resident altercation. * The facility failed to monitor the behavior of Resident 11 after he was witnessed exposing himself to another resident. [...]

Inspectors wroteBased on interview, medical record review, pharmacy document review, and facility P&P review, the facility failed to ensure the availability of a prescribed medication for one of 11 sampled residents (Resident 2). * Resident 2 had a physician's order for clozapine for schizoaffective disorder; however, the licensed nurses were unable to administer clozapine as ordered due to the unavailability of the medication. This failure posed the risk for inhibiting the therapeutic effects of the medication and had the potential to negatively affect the resident's health.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the nursing staff provided the nursing care to one of five sampled residents (Resident 1) status post an unwitnessed fall as evidenced by: * The facility failed to complete a 72-hour neurological check for Resident 1 after a fall as per facility P&P. * The facility failed to complete a Fall Risk Evaluation for Resident 1 after a fall as per facility P&P. These failures had the potential for the resident to not receive adequate care and risk for adverse complications post falls.

Inspectors wroteBased on interview and medical record review, the failed to protect one of four residents ' (Resident 3) rights to be free from the sexual abuse by Resident 4. This failure had the potential to negatively impact Resident 3 ' s mental and emotional well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to report the allegations of abuse to the CDPH in a timely manner when: * Resident 4 exposed his penis to Resident 3 who was also alleged Resident 4 of verbal abuse when he made racial remarks. This failure had the potential for Resident 3 and other residents to be exposed to further abuse.

Inspectors wroteBased on interview and medical record review, the facility failed to protect the residents' (Residents 1 and 3) right to be free from physical abuse by Residents 2 and 4. * Resident 2 had episodes of aggressive behaviors and refused the antipsychotic medications ordered by the physician. The facility failed to notify the psychiatrist that Resident 2's refusal as ordered which resulted in Resident 2's increase in agitation. Resident 2 struck Resident 1 on the face with a pitcher which resulted in Resident 1 sustaining head trauma and injuries on her face, arms, and legs. * Resident 4 punched Resident 3 in the face when Resident 3 refused to turn off a room light. This caused injuries to Resident 3's nose and upper lip.

Inspectors wroteBased on interview, facility document review, and facility P&P review, the facility failed to ensure the abuse allegations were thoroughly investigated for two of five sampled residents (Residents 1 and 2). This failure had the potential for the residents to be vulnerable for further abuse, mistreatment, and injury.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of five sampled residents (Resident 2) was free from unnecessary psychotropic medications. *The facility failed to monitor the behavioral manifestations and side effects associated with the use of olanzapine (antipsychotic medication) and vortioxetine (antidepressant). This had the potential for Resident 2's physician to lack the necessary information to determine the effectiveness of the medications.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to protect Resident 1 who was known to have wandering and behaviors of taking other people's foods and on 1:1 supervision from the physical abuse by Resident 2. Resident 2 had struck Resident 1 in the face during an altercation whenResident 1 had wandered into Resident 2's room and attempted to take Resident 2's milk. This failure resulted in Resident 1 suffering a left nasal bone fracture, blunt head and facial trauma, a cerebral concussion (a type of traumatic brain injury caused by a bump, blow, or jolt to the head which may cause damage to brain cells).

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the responsible party was informed in advance of the risks and benefits of their proposed treatment for one of five sampled residents (Resident 5). * The facility failed to ensure the informed consent was obtained from Resident 5's responsible party for the use of Remeron (an antidepressant drug which can be taken as an appetite stimulant) and Cogentin (a drug used to help control movement dysfunction, extrapyramidal symptoms). This failure had the potential for Resident 5 and their responsible party to not make informed medical decisions regarding Resident 5's care.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to notify the Long-Term Care Ombudsman of a transfer for two of five sampled residents (Residents 1 and 2). This posed the risk of the Long-Term Care Ombudsman not being aware of the circumstances should an appeal be filed by the resident or their representative regarding the transfer.

Inspectors wroteBased on interview, medical record review, and facility document review, the facility failed to ensure one of five sampled residents (Resident 3) wasprovided sufficient supervision to prevent wandering and elopement from the secured unit (a locked unit in the facility). * The facility failed to provide sufficient supervision and monitoring for Resident 3 who had a known history of elopement prior to admission and during admission in the facility. Resident 3 had a 1:1 sitter; however, the 1:1 sitter did not stay with Resident 3 all the time. As a result, Resident 3 eloped undetected through another resident's window on 11/1/23, and went missing until 11/3/23.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to protect one of five sampled resident's (Resident 1) rights to be free from the physical abuse by Resident 2. This had the potential for Resident 1 to be injured and have psychological harm.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the necessary care and services for two of four sampled residents (Residents 1 and 2) and 25 of 35 nonsampled residents (Residents 5, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, and 39) to maintain their highest physical well-being. * The facility failed to follow the physician's orders to administer Tea Tree oil to Residents 1, 5, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, and 39. * The facility failed to follow the physician's order to call for dermatology consult for Resident 5. [...]

Inspectors wroteBased on observation, interview, medical record review, facility document review and facility P&P review, the facility failed to implement their infection control practices designed to provide a safe and sanitary environment; and help prevent the development and transmission of diseases and infections as evidenced by: * The facility failed to implement their P&P to identify, isolate, and prevent the transmission of undiagnosed rashes, suspected scabies, and other opportunistic pathogens for the residents in the facility. * Residents 1 and 2 had history of scabies. The facility failed to place these residents on contact isolation precaution when the undiagnosed rashes or suspected to have scabies appeared to these residents. These failures caused the cross-contamination and spread of infectious organisms in the facility.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the plan of care was developed to address the residents' specific care needs related to rashes, scabies, oral lesion, and UTI for one of four sampled residents (Resident 2). This failure posed the risks for Resident 2 not receive the person-centered care and services required to attain or maintain her highest level of physical and mental well-being.

Inspectors wroteBased on interview and medical record review, the facility failed to provide the necessary care and services to maintain their highest physical well-being for one of 35 nonsampled residents (Resident 7). Resident 7 was admitted from the acute care hospital with history of right lower extremity diabetic ulcer and left lower extremity dry gangrene (death of body tissue due to lack of blood flow or serious bacterial infection). * The facility failed to conduct the skin and pain assessments, and pain monitoring for Resident 7's neck abscess and lower extremities with multiple wounds on admission 7/8/23. The wound care plan was not developed until seven days after admitting with the wounds. * The facility failed to follow the physician's orders for wound care treatment from 7/10 to 7/15/23, for Resident 7. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of four sampled residents (Resident 3) was free from unnecessary psychotropic medications. The facility failed to monitor behavioral manifestations associated with the use of quetiapine (antipsychotic medication) and divalproex (antiseizure medication used to treat bipolar disorder) and failed to monitor episodes of inability to sleep associated with use of trazadone (antidepressant medication) for Resident 3. This had the potential for Resident 3's physician not having necessary information to determine the effectiveness of the medications.

Inspectors wroteBased on interview and medical record review, the facility failed to maintain the complete and accurate medical records for two of four sampled residents (Residents 2 and 3). * The facility failed to ensure Resident 2's Triamcinolone (triamcinolone acetonide) treatment to oral lesions (mouth sores which may be painful) were accurately documented in Resident 2's TAR. * The staff failed to document care provided and percentage dinner intake on the Activities of Daily Living (ADL) Flowsheet on 8/19 and 8/20/23, for Resident 3. These failures had the potential for care needs for these residents not being met.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to maintain two of four shower stalls in the female shower room. This failure had the potential to pose risk of affecting the residents' health risk.

Inspectors wroteBased on observation, interview, facility P&P review, and facility document review, the facility failed to ensure the menu was followed as evidenced by: * [NAME] 1 failed to follow the recipe for the preparation of pureed Salisbury Steak. In addition, [NAME] 1 failed to ensure the correct portion sizes as shown in the recipe were provided the residents' meal tray. * [NAME] 2 failed to follow the recipe for nectar thick consistency in the preparation of the pureed salad. [NAME] 2 failed to ensure the correct portion sizes as shown in the recipe were provided to the residents' meal tray during tray line observation. In addition, [NAME] 2 added seasoned salt (not in the recipe) to the Fiesta Rice. * The facility failed to provide the appropriate portion size for Resident 637. Resident 637 had an order for a double portion of CCHO diet. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food safety and sanitation requirements were met in the kitchen as evidenced by: * The black and white residues were observed on the interior portion of the kitchen ice machine. An orange residue was observed inside the ice machine located in a room outside the kitchen. * A thawed, uncooked chicken dated from 3 days ago was observed in the refrigerator. * A moldy onion was found in a plastic bag inside the refrigerator. * [NAME] 2 failed to perform hand hygiene prior to food preparation. * Dietary Aide 1 scooped ice from the ice bin using a cup and did not perform hand hygiene. * [NAME] 2 failed to monitor the food temperature when she prepared the tuna salad. * The kitchen's cutting board surface was heavily marred. * The frying pan used for cooking had a black thick buildup. [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the licensed nurses had specific competencies and skill sets needed to care for the residents. * The facility failed to ensure a program or system was in place to check the competencies and skill sets of the licensed nurses at the facility upon hiring and ongoing basis. * LVN 2 failed to properly check Resident 53's GT residual before providing a bolus feeding. * The ADON, RN 2, and LVNs 2 and 8 failed to demonstrate how to obtain the history of the volume of feeding and water flush via the enteral pump for Resident 49. These failures had the potential to put residents at risk for care not provided in a safe and competent manner.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to implement their policies to provide pharmaceutical services to meet the needs of the residents. * The facility failed to ensure the Station 1 Medication Cart A glucometer was calibrated regularly. * The facility failed to ensure the disposition of non-controlled medications for discharged residents were accurately documented. * The facility failed to ensure the disposition of Residents 786's hydrocodone-apap (narcotic pain medication) was accurately documented. Thirty tablets of hydrocodone-apap were unaccounted for. * The facility failed to ensure the licensed nurses were accurately documented the narcotics administered to Resident 17 and 123 in the MARs. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility's P&P review, the facility failed to ensure 11 of 27 final sampled residents (Residents 4, 18, 55, 93, 111, 113, 114, 116, 120, 130, and 637) were free from unnecessary psychotropic medications. * The facility failed to provide documented rationale from the physician for increasing the dose of Ativan for Resident 120. * The facility failed to ensure Resident 4's episodes of behavior for the use of olanzapine (antipsychotic medication) were summarized on a monthly basis to serve as reference for gradual dose reduction. In addition, Resident 4 was not properly monitored for orthostatic blood pressure (measure the blood pressure while laying down or sitting and again upon standing up) as ordered by the physician for the use of an antipsychotic medication. [...]

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the kitchen staff had the appropriate skill sets to safely perform the daily operations of the Dietary Department as evidenced by: - [NAME] 1 was unable to follow the recipe for Salisbury steak, provide correct portions sizes for the lunch meal service, verbalize the correct cool down procedure for time temperature control for safety foods, and state the correct final cooking temperature for reheating poultry. - [NAME] 2 was unable to follow the recipes for the puree fresh green salad and the fiesta rice, and verbalize the correct cool down procedure for time temperature control for safety foods. - Cooks 2 and 3, and Dietary Aide 1 were unable to accurately test the sanitizing solution used to sanitize food preparation surfaces in the kitchen. [...]

Inspectors wroteBased on interview and facility document review, the facility failed to employ a full-time qualified social worker in accordance with federal law as required for a facility licensed for 120 or more beds. This failure had the potential for the residents to not receive necessary treatment and health services provided by a qualified social worker.

Inspectors wroteBased on observation, interview, medical record review, and facility document review, the facility failed to maintain the infection control practices to help prevent the development and transmission of diseases and infections. * The facility failed to ensure Resident 436 who was quarantined for COVID-19 precautions did not leave the quarantine area to be potentially exposed to other residents in the facility. * The facility failed to show documentation of Legionella testing protocols. * CNA 9 failed to perform hand hygiene before and after providing care. * The facility failed to ensure Resident 116's TB testing was done as ordered by the physician. These failures posed the risk of infection and the transmission of disease-causing microorganisms.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure four of 27 final sampled residents (Residents 114, 116, 120, and 130) and one of five unnecessary medication sampled residents (Residents 104) were provided the rights to self-determination regarding the psychotropic medication (medication affecting brain activity) use. * The facility failed to ensure the informed consents were obtained prior to the use of risperidone (antipsychotic medication) , quetiapine (antipsychotic medication), sertraline (antidepressant medication), and buspirone (antianxiety) for Resident 116. * The facility failed to ensure the informed consents were obtained prior to the use of Ativan (antianxiety medication) for Residents 120 and 104. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 27 final sampled residents (Resident 9) was assessed to determine if the resident was safe to self-administer the medications. * There were multiple bottles of supplements observed at Resident 9's bedside. This failure had the potential for medication interactions and inappropriate use of medications.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the advanced directives (written statement of a person's wishes regarding medical treatment) was obtained for one of 27 final sampled residents (Resident 85). This failure had to the potential for resident to receive inaccurate and delayed treatment compatible with the resident's wishes during an emergent situation.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to notify the physician and responsible party of a change in condition for one of 27 final sampled residents (Resident 53). This failure had the potential for a delay in prescribed treatments and interventions which posed the risk of negative health outcomes for Resident 53.

Inspectors wroteBased on observation, interview and facility P&P review, the facility failed to provide a homelike environment for one nonsampled resident (Resident 103). * The facility used a white blanket to cover Resident 103's sliding patio door instead of a curtain. The white blanket did not cover the full length of the sliding patio door. This failure posed the risk for Resident 103 to develop emotional distress.

Inspectors wroteBased on observation, interview, medical record review and facility P&P review, the facility failed to ensure one of 27 final sampled residents (Resident 53) was free from abuse. * The facility failed to protect a vulnerable resident (Resident 53) from abuse when RN 1 failed to assess him timely when he was admitted to the facility. Resident 53 who had severe cognitive impairment was admitted to the facility on [DATE] at 1030 hours. One and a half hours later, Resident 53 was found lying in his bed with a white sheet covering his face and both of his lower legs were bound together with a white sheet tied in two knots. This prevented Resident 53 from moving of his lower extremities. This failure had the potential to cause serious injury and physical and/or psychosocial harm to the resident.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to report an incident of abuse to the California Department of Public Health (CDPH) Licensing and Certification (L&C) Program, California Department of Aging, Long-Term Care Ombudsman Program, and law enforcement for one of 27 final sampled residents (Resident 53). * Resident 53 who had severe cognitive impairment and was totally dependent on staff for his ADL care, was found lying on his bed with both legs tied together with a fitted sheet on 8/23/21 at 1205 hours. The facility failed to report the abuse incident to the state agencies 29 hours after the incident had occurred. This failure had the potential for the resident to be vulnerable for further abuse.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of three closed record sampled residents (Resident 137) was safely discharged from the facility. * The facility failed to follow their P&P for Resident 137's discharge AMA (Against Medical Advice) as evidenced by a failure to discuss with the resident the risks and consequences associated with his decision to discharge from the facility AMA, failure to document the resident's stated reasons for his desire to leave the facility, failure to obtain a physician's order for discharge AMA, and failure to document whether the facility attempted to arrange necessary safe transportation for the resident. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the level 1 PASRR (used to ensure residents with a mental disorder are evaluated and receive care in a setting appropriate to meet their needs) contained accurate information for two of 27 final sampled residents (Residents 37 and 71). * Resident 71 had a diagnosis of schizoaffective disorder and was prescribed quetiapine; however, the level 1 PASRR showed Resident 71 had no diagnosed mental illness and was not prescribed the psychotropic medications. * Resident 37 had a diagnosis of depressive disorder; however, the level 1 PASRR showed Resident 37 had no diagnosed mental illness. [...]

Inspectors wroteBased on interview and medical record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of 27 final sampled residents (Resident 104) to meet the resident's medical and nursing needs. The facility failed to ensure a care plan was developed to address Resident 104's anxiety problem and the use of Ativan. This failure could potentially negatively impact the care needed for the resident.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the plans of care for two of 27 final sampled residents (Residents 49 and 120) were revised to address the residents' specific care needs. * Resident 49's care plan addressing risk for dehydration was not revised when the resident was diagnosed with dehydration. * The facility failed to ensure Resident 120's care plan was revised to address the use of wanderguard. These posed the risks for the residents to not receive the care and services required to attain or maintain their highest level of physical and mental well-being.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the necessary care and services for two of 27 final sampled residents (Residents 49 and 59) to maintain their highest physical well-being. * The facility failed to complete the CBC and CMP laboratory tests for Resident 59 as per the physician's order. * The facility failed to ensure the abdominal binder was applied to Resident 49 as per the physician's order. These failures had the potential to affect Residents 49 and 59's well being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure the residents were free from accidents and hazards. * The facility failed to provide adequate supervision to one nonsampled resident (Resident 436) who had behaviors of wandering and entering other resident rooms. * A metal drain grate missing one of nine slats was observed on the outdoor resident patio, which created a gap large enough for the front wheel of a resident's wheelchair to become entrapped. These failures had the potential to place the residents at risk for serious injury.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for one of 27 final sampled residents (Resident 49), to ensure the resident maintained an acceptable nutritional status. The facility failed to administer the enteral feeding via GT as ordered by the physician. This failure had the potential for not meeting the resident's nutritional needs.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure proper GT care for one of 27 final sampled residents (Resident 53) as evidenced by: * The facility failed to ensure Resident 53 was not lying flat when administering a bolus (a single dose of medication or other substance given over a short period of time) and enteral (refers to the intake of food through a gastrostomy tube) feeding to Resident 53. In addition, the facility failed to properly check the gastric residual volume (volume of fluid remaining in the stomach) before providing a bolus enteral feeding to Resident 53. These failures posed the potential risk for Resident 53 to have aspiration during feeding and medication administration.

Inspectors wroteBased on observation, interview, medical record review, and the facility P&P, the facility failed to ensure one of 27 final sampled residents (Resident 113) received the proper care of the peripheral catheter. * The licensed nurse failed to ensure the peripheral catheter dressing was labeled with the date and time when it was changed or applied on the peripheral catheter. This posed the risk for the resident to develop complications such as catheter- related infection or catheter-associated venous thrombosis (blood clot inside the vein).

Inspectors wroteBased on observation, interview, medical record review, and facility's P&P review, the facility failed to ensure one of 27 final sampled residents (Resident 4) was assessed for pain and provided non-pharmacological interventions to ensure adequate pain management. This had the potential for Resident 4's pain not being managed effectively.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to implement fluid restriction for one of 27 sampled residents (Resident 96) as per the physician's order by monitoring the fluid intake. This failure had the potential for Resident 96 to experience life threatening conditions associated with fluid deficit/overload.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure two of 27 final sampled residents (Resident 129 and 93) remained free from accident hazards due to the use of elevated side rails. *The facility failed to conduct the assessments for the risk of entrapment from side rails for Residents 116 and 129 and failed to attempt other interventions for Resident 116 prior to installing the side rails. These had the potential to put the residents at risk for entrapment and serious injury.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 6.89 %. One of two licensed nurses (LVN 9) was found to have made errors during the medication administration observation. This had the potential to negatively impact the residents' health outcomes.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the medications were safely and securely stored. * Medication Cart A contained the prescription drugs, was left unlocked, and unattended in the hallway. * Multiple bottles of medications were observed at Resident 9's bedside. These failures posed the risk of unauthorized access to the medications and drug diversion.

Inspectors wroteBased on observation and interview, the facility failed to ensure 18 of 136 residents received pureed foods that were prepared by methods to conserve nutritive value. This failure placed residents receiving a pureed diet at risk for nutritional impairment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve food to meet the individual need for one of 27 final sampled resident (Resident 113). * Resident 113 was served a regular texture broth during lunch. Resident 113 had an order for puree honey thick liquid ( thickened liquid to prevent from going into the lungs). This failure had the potential to result in Resident 113 to develop aspiration and choking emergency.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the food items brought to the residents from the outside were handled to ensure safe storage, preparation and consumption. This failure posed the risk of resident food brought to the facility from the outside not being handled in a safe and sanitary manner which posed the risk of food borne illnesses.

Inspectors wroteBased on interview and medical record review, the facility failed to maintain the accurate medical records for three of 27 final sampled residents (Residents 85, 114, and 116). * Resident 85 had conflicting information documented in the medical record as to whether Resident 85 had formulated an advance directive for health care. * The facility failed to ensure the licensed nurses documented their inititals in the MARs when the medications were administered to Residents 114 and 116. These failures had the potential for the resident's care needs not being met as their medical information was inaccurate.

Inspectors wroteBased on interview, facility document review, and CMS guidelines, the facility failed to follow the current COVID-19 routine testing guidelines of facility staff for two of five sampled unvaccinated facility staff (CNAs 3 and 10) during the COVID-19 pandemic. * CNAs 3 and 10 who were not vaccinated against the COVID 19 virus were not tested for COVID 19 when the county's positivity rate was at 8.3%. This failure posed the risk for the spread of the COVID-19 virus to residents and other facility staff.

Inspectors wroteBased on observation and interview, the facility failed to ensure the call light system was functioned properly in a room occupied by two residents. The call ight indicator outside Room L did not lit up when pressed. This failure had the potential for the staff to not know when these residents needed assistance.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to maintain an environment free of pests for one of 27 final sampled residents (Resident 127) and one nonsampled resident (Resident 95). * Resident 127 kept dead cockroaches inside a plastic bag when staff did not address her previous concerns about pests in her room. * Fruit flies were observed inside and flying around Resident 95 's bag of red grapes. These failures had the potential to cause the spread of infection throughout the facility.