Riverside Postacute Care

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a comfortable environment for 12 of 151 residents (Residents 2, 3, 4, 5, 6, 7, 8, 9,10, 11, 12 and 13), when the temperature in the resident's rooms was above 81 degrees Fahrenheit. This failure has the potential to result in physical discomfort which could lead to fatigue, mood swings, and respiratory and allergy issues, for Residents 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, and 13.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident's bedroom window blinds were maintained in good working order for 14 of 63 rooms reviewed (rooms 9, 11, 16, 23, 29, 31, 33, 34, 41, 52, 54, 57, 58, and 61) when missing and broken blinds were observed for rooms facing a residential street, the facility courtyard, and the visitor/employee parking lot. This failure affected Resident 2, 3, 4, and 5's privacy, comfort, and ability to regulate natural lighting and privacy within their rooms (16, 41, and 57), and had the potential to affect the privacy of the other residents residing in rooms 9, 11, 23, 29, 31, 33, 34, 52, 54, 58, and 61. On July 1, 2026, at 10:32 am, a facility tour was conducted. An observation of rooms 9, 11, 31, 41, 57, 58, and 61, that face the facility's courtyard, had missing vertical blind slats; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a physician's order of one-to-one sitter (1:1 sitter - a person who can provide continuous observation) was consistently implemented for one of three residents, Resident 2. As a result, Resident 2 was left unsupervised which may have contributed to Resident 2 having another fall incident on May 14, 2026, where Resident 2 sustained a skin tear to his left elbow. In addition, this failure had the potential for Resident 2 to sustain major injury such as a fracture (break in the bone).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medical record accurately reflected care and services provided for one of three residents (Resident 1) when Resident 1's meal assistance and meal intake tasks had multiple missing entries. This failure resulted in incomplete medical records and had the potential to result in ineffective communication between staff members in monitoring Resident 1's nutritional status and response to care.

Inspectors wroteBased on interview and record review the facility failed to ensure residents who have trust accounts (a bank account utilized to manage residents' finances) managed by the facility received quarterly statements, for five of five residents reviewed (Resident 7, 9, 10, 11, and 12). This failure had the potential to prevent residents and/or resident's representatives from verifying resident account balances, identifying potential discrepancies, and tracking interest earned.

Inspectors wroteBased on interview and record review, the facility failed to ensure the personal funds for four of five residents reviewed (Resident 7, 10, 11, and 12) were not charged for services covered by their Medi-Cal (California need-based program covering long-term room, board, and nursing care for eligible residents who meet specific income/asset limits) healthcare benefits. This failure resulted in an improper reduction of Residents 7, 10, 11, and 12 personal funds.

Inspectors wroteBased on interview and record review, the facility failed to ensure a secure environment for personal funds for four of five residents reviewed (Residents 7, 10, 11, and 12), when the facility changed the residents to private pay and removed $16,197.50 from the residents trust account (a bank account utilized to manage residents' finances) on [DATE], for Private Room & Board without the residents and/or Responsible Party (RP- primary point of contact that manages the resident's finances) consent. This failure had the potential for the residents and/or RP to experience mental anguish and/or confusion regarding the balance in their trust account.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident's representative (RP - primary point of contact that manages the resident's finances) for one of 5 residents reviewed (Resident 12), when Resident 12's trust account (a bank account utilized to manage residents' finances) balance approached the Supplemental Security Income (SSI) resource limit. This failure had the potential to place Resident 12 at risk of losing Medicaid (government program covering long-term care for low-income residents, including room and board, nursing care, therapies, and medications) eligibility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure seven of 39 residents reviewed (Residents 118, 106, 8, 153, 163, 108, and 69) were free from significant medication error when:1. Resident 118 did not receive her medication Lacosamide (anticonvulsant medication used to treat seizures) from December 17, 2025, to January 15, 2026. This failure had the potential to place Resident 118 at high risk for seizure and other complications;2. Resident 106 did not receive five doses of the medication Acyclovir (antiviral medication to treat infection) from February 22 to February 23, 2026. This failure had the potential to jeopardize Resident 106's health status by leaving a skin infection untreated, leading to delayed healing and increased risk of viral spread;3. [...]

Inspectors wroteBased on interview and record review, the facility failed to have a written Quality Assurance Performance Improvement (QAPI - a systematic, interdisciplinary, comprehensive, and data-driven approach to maintain and improve safety, quality of care, and quality of life of the residents) plan in place to address the facility's systemic process issues related to timely response to call lights. This failure resulted in delayed response to residents' call lights and placed residents at risk of not achieving their highest physical, mental, psychosocial well-being. A recertification survey was conducted between February 23, 2026, and March 3, 2026. During the survey, systemic issues were identified with timely response to residents' call lights (Cross Reference F725). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure equipment in the kitchen was maintained in a safe operating condition when the kitchen steam table (appliance designed to hold prepared food at safe, hot serving temperatures using heated water or steam) was not fully functional from December 19, 2025, to February 3, 2026. This failure had the potential to place vulnerable population of residents who receive food from the kitchen at risk for not receiving quality food.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff knocked and received permission prior to entering multiple resident rooms for six out of 14 sampled residents (Residents 15,18, 87, 67, 81, and 183). This failure had the potential to compromise resident's rights to dignity, respect, and privacy for Residents 15, 18, 87, 67,81, and 183 .

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure four of 39 residents (Resident 5, 30, 87, and 162), had the call light within reach. This failure resulted in Resident 5, 30,87, and 162 not to have a means of contacting the staff for assistance.

Inspectors wroteBased on interview and record review, the facility failed to ensure, 10 of 39 residents reviewed for Advance Directive (AD - written statement of a person's wishes regarding medical treatment) (Residents 1, 10, 14, 15, 30, 57, 89, 106, 156, and 176) the resident or their resident representative (RP) had been provided follow up information regarding the formulation of an AD.These failures had the potential to result in the ADs for Residents 1, 10, 14, 15, 30, 57, 89, 106, 156, and 176, not being readily accessible to staff and physicians, which could lead to the residents' wishes regarding medical treatment being unknown and ultimately not honored.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide sufficient nursing staff to be able to provide for care and services for the residents of the facility. This failure caused delays in the response to multiple residents' (Residents 19, 39, 43, 62, 108, 121, 124, 128, 183, 148, 150, 97, 13, 87, 108, and 162) call lights which had the potential to put residents at risk for falls, accidents, late provision of care or care not being rendered at all.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pharmacy services were provided in a timely manner, for 14 of 39 residents reviewed (Residents 118, 106, 8, 153, 13, 163, 108, 69, 182, 185, 184,186, 176, and 167) for pharmacy services, when:1. For Resident 118, 106, 8, 153, 13, 163, 108, and 69, medications were not administered as ordered by the physician on multiple occasions between December 2025, January 2026, and February 2026, due to medication unavailability. (Cross Reference F760).2. Residents 182, 185, 184, and 186, did not receive the PPD skin test (test to detect Tuberculosis {contagious lung infection}) as scheduled due to unavailability of the PPD solution;3. For Residents 176 and 167, the facility did not establish a system for receiving and ensuring Over-The Counter (OTC) medications are readily available for residents' use; and4. [...]

Inspectors wroteBased on observation, interview, and record review, the Pharmacy Consultant (PC) failed, for eight of 39 residents reviewed for pharmacy services (Residents 118,106, 8, 153, 63,108, and 69), to identify drug irregularities when multiple licensed nurses were documenting in the electronic medication Administration Record (eMAR) prescribed medications were not administered on multiple occasions between December 2025, January 2026, and February 2026, due to medication unavailability. (Cross Reference F760). This failure resulted in these residents not receiving medications as ordered by the physician to manage and treat medical conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper infection control measures were implemented when:1. For Resident 66, there was no EBP (Enhanced Barrier Precaution - an infection control strategy in nursing homes requiring staff to wear gowns and gloves during high-contact resident care, such as bathing, dressing, or device care) signage posted at the door outside Resident 66's room who had a urinary catheter (a flexible tube used to drain urine); 2. A kitchen staff was observed to touch the kitchen floor and continued with food handling without washing hands and changing gloves; 3. For Resident 106, the CNA attempted to reapply resident 106's nasal cannula after it had been on the floor; 4. The staff failed to hand sanitize in between meal tray pass; and 5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light system (a communication system that allow the residents to call for staff assistance) was fully functional when the call light system panel did not have an audible sound. This failure had the potential for the residents in the facility not to receive assistance from the staff in a timely manner.

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of physical abuse was reported within two hours to the California Department of Public Health (CDPH - State Agency Licensing and Certification Program) for one of 39 residents reviewed (Resident 20). This failure had the potential to result in a delay in the investigation and reporting further allegations of abuse for Resident 20.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure for two of 39 residents reviewed for quality of care (Residents 47, and 108) the following:1. For Resident 47, the medications Equate (brand name) Multivitamins and Over-The-Counter (OTC) throat lozenges found at the bedside had a physician's order for use. This failure had the potential for Resident 47 to not be monitored for safe self-administration of medication and medication side effects; and2. For Resident 108, the facility did not ensure a laboratory order to monitor the effectiveness of the thyroid medication was in place. This failure had the potential for Resident 108 to not be monitored for complications related to hyperthyroidism (overactive thyroid).

Inspectors wroteBased on observation, interview, and record review, the facility failed for three of 39 residents reviewed for oxygen administration (Residents 29, 206, and 181) when:1. For Residents 29 and 106, respiratory care and treatment were not provided when the physician's order for oxygen administration was not followed. This failure had the potential to result in ineffective oxygen therapy, respiratory distress, and decline in the residents' health condition; and2. For Resident 181, the facility did not ensure the resident's oxygen tubing was labeled in accordance with the facility practice. This failure had the potential to result in cross-contamination, increasing the spread of infection to an already vulnerable population of residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident's food preference was honored for one of three residents (Resident 108). This failure had the potential to result in the resident refusing meals and experiencing decreased nutritional intake.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the policy and procedure for Self-Administration of Medications was followed for one of six residents, (Resident 4). This failure had the potential for Resident 4 to overdose, have medications in an unsecured location, and staff to be unaware of the medications Resident 4 was taking.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights were answered in a timely manner when one of six residents (Resident 1), waited for 31 minutes for his call light to be answered when he wanted his briefs changed. This failure had the potential for Resident 1's needs to be unmet and experience possible skin breakdown due to wearing a wet brief for an extended period of time.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, for four of four sampled residents, Residents 2, 3, 4, 5, the residents and/or their responsible party were notified of payor changes when the residents were changed from Medi-cal to private pay. This failure is a violation of Residents 2, 3, 4, 5 and/or their responsible parties of resident's rights.

Inspectors wroteBased on interview and record review, the facility failed to provide copies of financial records upon request within two business days after receiving the request from the Long-Term Care Ombudsman (LCTO- an advocate who assists residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences) on behalf of the resident, for one of six sampled residents, Resident 2. This failure is a violation of Resident 2 and the resident's representative's rights.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to protect the residents' rights to be free from sexual abuse by another resident and verbal abuse by a staff member for two of the ten residents reviewed (Resident 1 and Resident 7) when: 1. For Resident 1, staff witnessed a male resident (Resident 2) touching Resident 1's breast with one hand and trying to raise Resident 1's shirt up with the other hand; and This failure has the substantial probability of causing Resident 1 to experience anxiety, emotional distress, or fear of recurrence of the sexual abuse which could subsequently lead to decreased engagement in social activities by Resident 1. 2. For Resident 7, another resident (Resident 9) witnessed the CNA (certified nurse assistant) verbally abused Resident 7, by telling Resident 7 to shut up when the resident was crying. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe environment and adequate supervision were provided for two of four sampled residents (Residents 2 and 3), when Residents 2 and 3 were observed to have smoking paraphernalia kept at bedside. In addition, the facility failed to ensure Resident 2's capability and deficit was assessed to determine the need for assistance and supervision for smoking. These failures had the potential for environmental risk, hazards and accidents resulting in serious burn injuries and/or fire for Residents 2 and 3 and other residents at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure bedside water pitchers were filled or that fresh water was offered daily to maintain proper hydration for two of seven sampled residents (Residents 1 and 7). This failure has the potential to adversely impact the residents' hydration status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when Licensed Vocational Nurse (LVN) 1 did not wear the appropriate personal protective equipment (PPE - specialized clothing or equipment worn to create a barrier between healthcare workers and potential sources of infection, like blood, body fluids, or other potentially infectious materials) when she entered the room of a COVID-19 (SARS-CoV-2-a highly contagious respiratory disease) positive resident. This failure had the potential to spread COVID-19 to other residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the residents' right to be free from physical abuse by a staff member for one of three residents reviewed (Resident 1) when a Certified Nursing Assistant (CNA) placed a towel over Resident 1's mouth. This failure had the potential to obstruct Resident 1's breathing causing suffocation and the risk of aspiration (inhaling food, liquid, or foreign material into the lungs), and emotional distress.

Inspectors wroteBased on interview, and record review, the facility failed to ensure an allegation of physical abuse involving one of three residents reviewed, Resident 1, was reported to the California Department of Public Health (CDPH), not later than two hours after the allegation was made. This failure resulted in a delay in an investigation being started and had the potential to place Resident 1 and other residents at risk of harm from further abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that Resident 1 received necessary care and services in accordance with the resident's comprehensive assessment and professional standards of practice when the facility did not conduct a comprehensive interdisciplinary assessment of transportation needs to ensure safe and proper transport to and from dialysis appointments for 1 of 3 sampled residents (Resident 1) reviewed for dialysis. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and revise a comprehensive, person-centered care plan to address transportation needs for one of three sampled residents (Resident 1) reviewed for dialysis. The facility did not complete an interdisciplinary assessment or care plan update when it changed the resident's transportation method for dialysis from a wheelchair-accessible van to a standard vehicle (Uber). As a result, the resident was transported in an inappropriate vehicle that did not accommodate her functional limitations, leading to missed dialysis treatments, hospitalization, and physical injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when: 1. One jar of minced garlic in the walk- in refrigerator was found to be past its used by date and was readily available for use; 2. Several Romaine lettuces were observed in the walk-in refrigerator not properly stored within their designated bags and exposed to open air; 3. One brown cutting board was found with multiple deep indentations; 4. Two hot water thermos water spurs were found with calcium build up and brown grime above the spurs; 5. Two dietary staff did not follow the manufacturer's guidelines for testing QUAT sanitizer concentration with a test strip; and 6. Two dietary staff did not know the correct concentration of the dishwasher sanitizer. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure, 10 of 38 residents reviewed for Advance Directive (AD - written statement of a person's wishes regarding medical treatment) (Residents 1, 9, 13, 28, 36, 123, 126, 155, 157, and 168) the resident or their resident representative (RP) had been provided follow up information regarding the formulation of an AD.These failures had the potential to result in the ADs for Residents 1, 9, 13, 28, 36, 123, 126, 155, 157, and 168, not being readily accessible to staff and physicians, which could lead to the residents' wishes regarding medical treatment being unknown and ultimately not honored.

Inspectors wroteBased on interview and record review, the facility failed to ensure for four of five certified nurse assistants (CNAs 1, 2, 4, and 5) performance evaluations were completed. This failure had the potential for staff performance needs not to be identified and addressed in a timely manner.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper infection control measures were implemented when:1. For Resident 86, Licensed Vocational Nurse (LVN) 4 did not wear personal protective equipment (PPE - equipment, such as gloves and gown, used to protect against infection or illness) when providing care to Resident 86, who was on enhanced barrier precaution (EBP-an infection control intervention to reduce transmission of multidrug-resistant organisms [MDRO- bacteria that have become resistant to multiple antibiotics).2. For Resident 116, Certified Nursing Assistant (CNA 1) did not wear personal protective equipment when providing care.3. For Resident 64, LVN 5 did not use the proper disinfecting wipes to clean the blood pressure machine between residents' use.4. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a written Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN- a notice to provide information to residents/beneficiaries if they wish to continue receiving the skilled services that may not be paid for by Medicare and assume financial responsibility) for one of three residents reviewed for SNF ABN (Resident 92). This failure resulted in Resident 92 not being informed in writing about potential liability for payment of non-covered Medicare Part A services, placing the resident at risk of unexpected financial burden.

Inspectors wroteBased on interview and record review, the facility failed to ensure reasonable care for the protection of resident's property for two of three residents (Residents 120 and 147) when: 1. The personal inventory list was not available for Resident 120 and2. The inventory of personal belongings list was incomplete for Resident 147. These failures resulted in the inability to verify and account for residents' belongings which had the potential to result in psychosocial harm for Residents 120 and 147.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all residents were free from abuse when one of five residents (Resident 168) reviewed for abuse was verbally abused by another resident (Resident 10), after Resident 168 asked Resident 10 to lower the volume of his music. Resident 10 verbally threatened Resident 168 and called him derogatory names. The facility failure resulted in Resident 168 feeling threatened by Resident 10, which could negatively impact the resident's psychosocial well-being.

Inspectors wroteBased on interview and record review the facility failed to incorporate the recommendations from the PASARR level II determination and evaluation into the care plan for one (Resident 123) of two residents reviewed for PASRR (Pre-admission Screening & Resident Review- a federal requirement to determine whether or not an individual who has an active diagnosis of mental illness or intellectual disability meets the criteria for admission to a nursing facility and identify what specialized services an individual needs). This failure had the potential for Resident 123's special needs not to be met while in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care and services to maintain cleanliness and proper hygiene of resident's fingernails, for one of two residents reviewed (Resident 174). This failure had the potential for Resident 174 to be at risk for infection due to the unsanitary condition of his fingernails.

Inspectors wroteBased on interviews and record reviews, the facility failed to complete monitoring for a skin related change of condition for one of one resident (Resident 12) reviewed for quality of care. This failure resulted in inconsistent evaluation of the wound and placed Resident 12, who had diabetes (abnormal blood sugar) and peripheral vascular disease (a problem with blood flow), at risk for infection, delayed wound treatment, and worsening of the condition of the left second toe.

Inspectors wroteBased on interviews and record review, the facility failed to adequately monitor nutritional status for one of two residents (Resident 126) when meal intakes were not consistently documented. This failure had the potential to result in inability to track intake trends, identify weight loss risk, and delay in corrective action subsequently resulting in nutritional decline.

Inspectors wroteBased on interview and record review, the facility failed to follow dental recommendations for one of two residents (Resident 138) reviewed for dental services. This failure had the potential for nutrition problems, discomfort, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light system was working properly for one of twelve resident call lights (Resident 5). This failure had the potential to delay medical care needed for Resident 5.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient staffing to be able to provide care and services to the residents of the facility. This failure caused the delay in response to the resident's call lights being answered and had the potential for late provision of care or the care not being rendered at all.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care and treatment according to professional standards of practice when one of three residents (Resident 8) was administered Midodrine (a medication used to treat orthostatic hypotension - low blood pressure that occurs upon standing) when Resident 8's blood pressure (BP) was above the physician's ordered parameters. This failure had the potential for Resident 8 to experience hypertension (high blood pressure).

Inspectors wroteBased on interview, and record review, the facility failed to inform one of three residents (Resident 7) of a change in her insurance that occurred while she was at the facility. This failure resulted in Resident 7 not receiving the planned care and services upon her discharge from the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a comfortable and sanitary environment for two of two residents (Residents 2 and 3) when:1. Resident 2's sheets were not changed, and Resident 3's urinals (a portable device used for urination) with urine were left hanging on the bed and on the bedside table, and2. A bag of soiled linen was left on the floor of another room. This failure resulted in Resident 2 and 3 not to have a sanitary and comfortable environment.

Inspectors wroteBased on interview and record review, the facility failed implement their policy and procedure when the facility failed to ensure an allegation of physical abuse was reported within two hours to the California Department of Public Health (CDPH - State Agency Licensing and Certification Program) for one resident (Resident 9) of three residents reviewed for abuse. The facility's abuse policy, dated June 2022, documented that the facility would report all alleged incidents of abuse to CDPH within two hours. On July 31, 2025, it was alleged that a facility staff member forcibly transferred Resident 9 to her wheelchair. The facility failed to report the allegation until over four hours after the incident, at 6:31 a.m. This failure had the potential to result in delaying resident protection and delaying the start of an investigation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure routine Norco (narcotic pain medication) was available for one of two residents (Resident 1), when Resident 1 did not receive four doses in June 2025, and nine doses in July 2025. This failure had the potential for Resident 1 to experience psychological distress and unmanaged pain.

Inspectors wroteBased on interview and record review, the facility failed to provide wound treatment for one of two residents' (Resident 4) left lower extremity open wound for three days since admission to the facility. This failure of delayed provision of wound treatment can lead to serious complications like sepsis, infection and even amputation.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was free from physical abuse, when two facility staff witnessed one Certified Nursing Assistant (CNA 1) roughly pushed one of three sampled residents (Resident 1) multiple times, to prevent resident from getting up from bed. Resident 1 has severe cognitive impairment. This failure could very likely result in Resident 1 experiencing increased anxiety and distress which negatively impact Resident 1's psychosocial, and mental well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to, for one of three sampled residents (Resident 3): 1. Re-assess the blister on the right elbow of Resident 3, initially observed during re-admission to the facility on April 13, 2025, and 2. Administer treatment to Resident 3's right elbow blister, when it was observed on April 13, 2025. These failures resulted in the worsening of the right elbow blister to a Stage 4 pressure injury (bed sore-full thickness skin loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer).

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of physical abuse involving one of three sampled resident (Resident 1) and a facility staff was reported to California Department of Public Health (CDPH - State Agency-Licensing and Certification Program) immediately or not later than two hours. The facility was made aware of the alleged physical abuse on March 5, 2025. This failure has the potential for delayed investigation which placed Resident 1 at risk for further abuse while at the facility.

Inspectors wroteBased on interview and record review, the facility failed to follow the proper procedure in removing blockage of the gastronomy tube (G-tube a tube placed through the abdominal wall directly into the stomach, typically for feeding purposes), in accordance with the policy and procedure for one of three sampled residents (Resident 2). This failure had the potential to negatively impact the resident's ability to receive nutrition, hydration and medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a written notice of bed hold policy (reserving a resident's bed while resident is out of the facility for therapeutic leave or hospitalization) was provided for two of three residents reviewed for hospitalization (Residents 1 and 2) when they were transferred to the general acute care hospital (GACH). This failure had the potential for Residents 1 and 2 to not be informed of their rights to hold the bed while out of the facility and the right to be readmitted back to the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sufficient staff were provided to meet the needs of the residents when: 1. For 9 of 161 residents, (Residents 42, 56, 66, 91, 103, 107, 132, 267, and 417) complained that staff failed to assist with activities of daily living (ADL- daily care activities) in a timely manner; and 2. Three (3) of nine (9) confidentially interviewed residents from the Resident Council meeting complained that call lights were not being answered timely, food was being served late, and residents were left sitting in their urine and bowel for long periods of time. These deficient practices caused feelings of frustrations and anger, among the residents, and negatively affected the quality of care for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure bedtime snacks were offered and were sufficient, for 153 of 153 residents who received food from the kitchen. This failure had the potential to affect the nutritional and psychosocial wellbeing of residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly when trash and used gloves were found on the floor surrounding the dumpsters. This failure had the potential to attract pests and cause infection control issue.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe, comfortable, and home like environment for the residents was provided when: 1. Comfortable temperature levels were not maintained for multiple resident rooms (Rooms 41B, 47C, and, 49B). This resulted in multiple residents feeling cold, especially at night (Residents 95, 102, and 119)and had the potential to have effect on resident's medical condition; and 2. There was no documented evidence weekly checks of laundry equipment were performed by the Maintenance Director (MD). In addition, additional laundry staff was not maintained to assist in washing and distributing personal clothing timely. This resulted in the residents' personal belongings to not be distributed timely and had the potential to affect the residents psychosocial well being

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure provision of pharmacy services met the needs of four of four residents when: 1. The licensed nurse discarded Resident 159's non-scheduled medication waste into a regular trash bin during the preparation for the medication administration. This failure had the potential for the misuse of the medications and environmental harm; 2. The licensed nurse left Resident 159's medications unattended on the resident's bedside table during the medication administration. This failure had the potential for misuse of the medications by the residents, facility staff and/or visitors; 3. Random controlled medication audit for Residents 12 and 128 did not reconcile. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure, for four of five residents reviewed for unnecessary medications (Residents 23, 38, 42, and 126) were free from unnecessary psychotropic (drug that affects brain activities associated with mental processes and behaviors) medications when there was no documented evidence of monitoring for the followings: 1. For Resident 38, Seroquel (antipsychotic medication to treat hallucinations and thought disorder), Buspirone (anti-anxiety drug, used to treat anxiety), and Depakote were ordered without a specific quantifiable monitoring for non-pharmacological interventions; 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper labeling and storage of medications in accordance with the facility policy and procedures and/or manufacturer's instructions when: 1. IV (intravenous) Mini-bag plus containers removed from or in an opened manufacturer's overwrap without beyond use dates were stored in IV Cart, Medication Cart 2, and Medication Cart 4; 2. Total of three expired medications were stored in Treatment Cart, Medication Cart 1, and Medication Cart 2; and 3. One discontinued medication was kept in stock in Medication Cart 2 along with other active medications. These failures had the potential for the residents to receive medications beyond their effective dates, receive expired medications and had the potential for residents to have access to the discontinued medications and administer it unsafely.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the dietary staff safely and effectively carried out the functions of food and nutrition services when (Cross Reference F812): 1. The food service workers did not follow the manufacturer's guideline regarding the length of time for testing the red bucket Quaternary (Quat) sanitizer (sanitizing solution used for sanitizing food contact surfaces); 2. The food service workers did not know the appropriate concentration of the Quat sanitizer; 3. Diet Aides (DA) 1 and 3 were unable to demonstrate the proper steps to clean the dirty meal carts; 4. [NAME] (CK) 2 and Diet Aide 2 did not know how to calibrate the food thermometer; and 5. Diet Aides 3 and 4 did not know how long they need to submerge washed kitchen ware in the sanitizer sink. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure food were prepared according to the prescribed recipe, when: 1. [NAME] 1 did not add margarine to a fortified diet during the noon meal on March 17, 2025; 2. Food service workers did not have a system to distinguish a diet Jello for Controlled Carbohydrate Diet during the noon meal on March 17, 2025; 3. [NAME] 2 did not use the right scoop to portion salad for dinner on March 18, 2025; 4. [NAME] 2 did not use the right scoop to portion meat for dinner on March 18, 2025; and 5. Diet Aide 5 did not measure the amount of shredded cheese to be placed in cheese quesadilla on March 18, 2025. These failures had the potential to negatively impact the residents' nutritional status and further compromising the resident's medical status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food were served at appropriate temperatures, were palatable (the taste and/or flavor of the food) and with variety of foods, according to the residents' preferences and the facility's policy and procedure, for nine residents (Resident 23, 35, 52, 66, 91, 103,107, 132, and 146) out of 153 residents who receive food from the kitchen. This failure placed residents at potential risk to decrease nutritional intake and affect the resident's nutritional status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the appropriate food texture was provided when: 1. For 13 of 13 residents who received pureed diet (is a diet with food texture need to blend until smooth for residents who have difficulty chewing and/or swallowing) received pureed meat that were not smooth with meat fiber still intact for dinner on March 18, 2025; 2. For Resident 39 who had a physician order for nectar thick liquid received lumpy milk and a regular shake during lunch on March 18, 2025; 3. For Resident 85 who had physician ordered for nectar thick liquid received pudding consistency milk and Jello during lunch on March 18, 2025; and These failures had the potential to place the residents at risk of choking, aspiration (when food is breathed into the lungs), coughing and decreased meal or fluid intake.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and distributed in accordance with professional standards for food service safety when: 1. Dust was observed on several areas (dry storage room and back door frame) in the kitchen; 2. Dietary Aide (DA 4) and Engineering Plant Director (EPD) had facial hair and were not wearing a hair restraint; 3. Two opened food items were exposed to the air in the walk-in freezer; 4. The walk in refrigerator gasket was found to have black grime buildup; 5. Three baking pans of pizza were stored underneath the steam table which was near a sanitizer bucket, and with air gap; 6. Wilting produce (three cucumbers and 2 green bell peppers) were found in the walk in refrigerator; 7. The cabinet used to store kitchen ware had chipped wood; 8. Two hot waterspouts had calcium buildup; 9. [...]

Inspectors wroteBased on interview and facility record review, the facility failed to ensure a written Quality Assurance Performance Improvement (QAPI - a systematic, interdisciplinary, comprehensive, and data-driven approach to maintain and improve safety, quality of care, and quality of life of the residents) plan in place to address the facility's systemic process issues related to staffing, dietary, and laundry services. These failures resulted in multiple residents to not receive appropriate services from Certified Nursing Assistant (CNA) staffing, dietary, and laundry services. In addition, these failures had the potential to place other residents residing at the facility to be at risk for not achieving their highest physical, mental, psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection prevention and control practices were upheld when: 1. During lunch meal observation on March 17, 2025, Resident 36's IV (intravenous- into the vein) tubing was observed touching the food on her plate; 2. Two laundry staff stated they did not routinely check the washer and dryer temperatures. In addition, they were not able to state what the temperature requirements were for washing and drying linen and clothes; and 3. One laundry staff was observed placing linen that was touched by a resident, back into an uncovered linen cart. In addition, the laundry staff covered the clean linen in a large linen bin, with a linen cover that came in contact with the floor. These failures had the potential to spread infection among the vulnerable residents of the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure the facility remained free of pests when four bugs, one (1) spider, and one (1) house fly were found in the kitchen. This failure had the potential to place 153 out of 153 residents who received food from the kitchen at risk for food borne illnesses (illness caused by food contaminated with bacteria, viruses, parasites or toxins).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure meals were served at the same time, for two of three residents (Residents 101 and 127) when: 1. Resident 101 was not served his lunch meal on March 17, 2025, at the same time as the other residents at the same table; and 2. Resident 127 was not served his lunch meal on March 17, 2025, and dinner meal on March 18, 2025, at the same time as the other residents at the same table. These failures increased the potential to negatively affect Resident 101 and 127's psychosocial well-being and could place the residents at risk to not consume the food served.

Inspectors wroteBased on interview and record review, the facility failed to ensure informed consents (process in which a health care provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention in order to obtain agreement or permission for care, treatment, or services) were obtained prior to the initiation and administration of psychotropic medications according to the facility's policy and procedure, for two of five residents reviewed for unnecessary medications (Residents 23 and 38). This deficient practice had the potential for the residents or the responsible party (RP) not to be informed of the risk and benefits of the psychotropic medications, and to make an informed decision, before receiving the medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure grievance were addressed, for one of three residents (Resident 55), when Resident 55 notified the facility staff of missing leg prosthesis. This failure had the potential for Resident 55 to have a decline in Activities of Daily Living (ADL) and could affect psychosocial and physical well being.

Inspectors wroteBased on interview and record review, the facility failed to issue a written notice of discharge to the resident (or resident representative) and to the Office of the Ombudsman, for one of one resident reviewed for hospitalization (Resident 10), when the resident was discharged from the facility while still at the general acute care hospital (GACH). This failure had the potential to result in the lack of coordination of support for Resident 10 during discharge planning or after discharge to the community and had the potential for Resident 10 to be not informed of his appeal rights.

Inspectors wroteBased on interview and record review, the facility failed to ensure medications were administered according to the physician orders, for one of 37 residents reviewed, (Resident 148). This failure had the potential to inadequately control Resident 148's blood pressure, pulse rate, and blood sugars, which could affect Resident 148's overall health condition.

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility's Consultant Pharmacist (CP) identified irregularities with medication therapy and made recommendations to the prescribing physicians during the monthly Medication Regimen Review (MRR), for three of five residents reviewed for unnecessary medications (Residents 38, 42, and 126) when: 1. Resident 38 was on duplicate Vitamin D (supplement) orders and received twice each day; 2. Resident 126 was on duplicate Omeprazole (medication for indigestion and heartburn) orders and received four times each day; and 3. Resident 42 was on routine opioid (medication for moderate to severe pain) therapy without bowel regimen. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents were free from unnecessary medications when same medications were ordered for the same strength, frequency and indication and not reviewed and clarified to prevent duplication of therapy, for two of five unnecessary medications sampled residents (Residents 38 and 126): 1. Resident 38 was on duplicate Vitamin D (supplement) orders and received twice each day; and 2. Resident 126 was on duplicate Omeprazole (medication for indigestion and heartburn) orders and received four times each day. These failures resulted in Resident 38 and 126 receiving excessive dose of medications and had a potential to result in accumulation of medication in the residents' body and adverse effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate during the medication administration observation was less than 5% when, the facility had a cumulative medication error rate of 13.79%. Four medication errors occurred out of 29 opportunities during the medication administration, for one of three residents (Resident 154). This failure resulted in medications not given in accordance with the physician's orders and the facility's policy and procedures, which had the potential for residents not receiving the full therapeutic effects of the medications and worsening of the residents' medical conditions

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, for one of five residents reviewed for unnecessary medications (Resident 119), was free from a significant medication error, when phenobarbital (medication used to treat seizure) was not administered to Resident 119, as evidenced by missing documentation of administration of the medication. This failure had the potential to result in seizure for the resident due to not receiving the full therapeutic effect of the medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a dental consultation was provided, for one of two residents reviewed for dental (Resident 38). This failure has the potential to place the resident at high risk for complications related to dental needs due to the possible delay in providing dental devices.

Inspectors wroteBased on interview and record review, the facility failed to ensure the dietetic services supervisor had received at least six hours of dietary service in-service training as required by Title 22 of the California Code of Regulations (State Agency regulations) prior to assuming full time duties as dietetic services supervisor. This failure resulted in the lack of required in-service training hours by the dietary service supervisor and could potentially affect the operations in the dietary services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure equipment in the kitchen was maintained in a safe operating condition when condensation ice buildup was found on the fans in the reach in freezer. This failure had the potential to place 153 out of 153 residents who received food from the kitchen at risk for not receiving quality of foods.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two residents, Resident 2, was provided timely access to her personal funds. This failure resulted in Resident 2 being upset and had the potential to result in anxiety (feeling of uneasiness) or a feeling of loss of control impacting her overall well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure treatments ordered by the physician were administered for two of two residents, Residents 2 and 5. This failure had the potential to result in worsening of Residents 2 and 5 ' s skin conditions.

Inspectors wroteBased on interview and record review, the facility failed to ensure the call light was functioning for one of three residents, Resident 1. This failure had the potential to result in Resident 1 not being able to call for help.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the room was safe for two of two residents, Residents 3 and 4, when the floor tile was broken inside their room. This failure had the potential for Residents 3 and 4 to have a fall.

Inspectors wroteBased on interview and record review, the facility failed to provide Registered Nurse (RN) coverage in the facility for 24 hours as indicated in their facility assessment (the foundation for the facility to assess its resident population and determine the direct care staffing and other resources to provide the required care to their residents). This failure had the potential to endanger the health and safety of all residents being cared for. In addition, this failure resulted in Resident 2 missing a scheduled IV (intravenous- giving medicines or fluids through a needle or tube inserted into a vein) on January 12, 2025.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the confidentiality of the residents ' protected health information (PHI) when two licensed nurses used their personal laptops (portable computers) for med pass (administration of medications). This failure had the potential to compromise the PHI of 59 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure for two of three residents, Resident 3 and 4, the overbed light had pull cords that were within their reach. This failure resulted in Residents 3 and 4 not having access to use the overbed lights.

Inspectors wroteBased on interview and record review, the facility failed to provide and document sufficient preparation and orientation to ensure a safe and orderly discharge from the facility for one of two residents, Resident 5, when: 1. Resident 5 was discharged to (name of recuperative care center - a short-term residential program that helps people recover form an illness or injury) without a referral; 2. The facility did not arrange home health for Resident 5; and 3. There was no documented evidence that Resident 5 was assessed for needed durable medical equipment (DME) such as a wheelchair and a walker. This failure had the potential to result in an unsafe discharge of Resident 5 back into the community.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure for one of two residents, Resident 3, her cup and water pitcher was within her reach. This failure had the potential to further increase Resident 3 ' s risk for dehydration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure for one of two residents, Resident 1, received his IV (intravenous-giving medicines or fluids through a needle or tube inserted into a vein) medication doses as ordered by the physician. This failure resulted in Resident 1 missing two doses of daptomycin (treatment for bacterial infections) and had the potential for Resident 1 to acquire further infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the laundry equipment in good working condition, when one washing machine and two clothes dryers were not functioning. One resident out of 15 residents reviewed (Resident 1) stated some of his personal clothes were missing. This failure had the potential to result in residents ' personal clothes not being washed, cleaned and returned timely, affecting the use of those personal belongings that support a homelike environment.

Inspectors wroteBased on record review and interview, the facility failed to ensure the resident's representative (RR) was invited and included in the interdisciplinary team (IDT) care planning meeting for one of three sampled residents (Resident 2). This failure resulted in the RR being uninformed and not being given the opportunity to participate in making decisions for Resident 2's plan of care, treatment, and healthcare goals that could affect Resident 2's care and quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of physical abuse was reported within two hours to the California Department of Public Health (CDPH-State Agency-Licensing and Certification Program) for one resident reviewed (Resident 1). This failure had the potential to result in a delay of investigation and reporting of further allegations of abuse.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident ' s rights to the confidentiality of medical records, for six of six residents, Residents 4, 5, 6, 7, 8 and 9, when the Licensed Nurses communicated residents ' information using non-HIPAA (Health Insurance Portability and Accountability Act - a federal law that required the creation of national standards to protect sensitive patient health information from being disclosed without the patient's consent or knowledge) compliant messaging applications and Registered Nurses used their personal mobile phones and phone numbers to communicate end of shift reports. This failure had the potential to compromise Residents 4, 5, 6, 7, 8 and 9 ' s protected health information.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe environment for three of three residents reviewed when: 1. Resident 1, who had an order for a Wanderguard (bracelet that trigger alarms on doors to alert staff if a resident leaves a safe area), eloped (when a resident leaves a healthcare facility without permission or when they are unable to make safe decisions on their own) from the facility. This failure had the potential to result in Resident 1 to sustain serious injury such as being struck by a vehicle or death; and 2. Residents 2 and 3 did not have their Wanderguard bracelets on them as ordered by the physician. This failure had the potential to result in Residents 2 and 3 to elope from the facility and have lack of access to needed health care.

Inspectors wroteBased on interview and record review, for one of two residents reviewed (Resident 3), the facility failed to ensure the resident ' s funds were conveyed to Resident 3 within 30 days of her discharge from the facility. This failure resulted in delayed conveyance of funds and financial resources that may be necessary for the delivery of health care needs after Resident 3 was discharged from the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure, for one of two residents (Resident 4), a one-to-one sitter (1:1 sitter - a person who can provide continuous observation) was provided as ordered by the physician. As a result, Resident 4 was left unsupervised during which time Resident 4 had two fall incidents in June 2024, and sustained skin tears during both incidents. In addition, this failure had the potential for Resident 4 to sustain major injury such as a fracture (break in the bone).

Inspectors wroteBased on interview and record review the facility failed to implement their policy for managing Resident ' s personal funds and contact the resident family first after the physician certified the resident was no longer able to handle financial matters, for four of seven residents (Resident 7, Resident 8, Resident 9, and Resident 10), reviewed for the representative payee program (a representative payee manages Social Security funds). This failure resulted in the residents ' and the residents ' representative ' s rights regarding their financial matters not to be recognized.

Inspectors wroteBased on interview and record review, the facility failed to ensure safe standard of nursing practice was followed for one of three residents reviewed (Resident 1) when the licensed nursing staff did not document the resident's vital signs (blood pressure, pulse, and respiratory rate) and update the plan of care after Resident 1 was found unresponsive and had left side body twitching. This failure had the potential to jeopardize the health and safety of Resident 1, and had the potential for the development of complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the appropriate fluid texture was provided for one of three residents (Resident 12) when kitchen staff did not have instructions for mixing thickener, and Resident 12 received nectar thick liquids instead of pudding thick liquids. This failure had the potential to place Resident 12 at risk of choking.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a system and follow the facility policy and procedure to ensure Preadmission Screening and Resident Review (PASRR; PASARR) Level I screenings were updated for three of four residents reviewed for PASRR (Residents 13, 14, and 15) when: 1. Resident 13 did not receive a new Level I screen after spending 30 days in the facility based on the recommendations of the initial Level I screen; 2. Resident 14 did not receive a new Level I screen when there was a significant change in condition; and 3. Resident 15 did not receive a new Level I screen after admission to the facility upon the recommendation of the Level II screener, prior to admission. These failures had the potential to result in the residents not receiving the care and services required to maintain their psychosocial well being.

Inspectors wroteBased on interview and record review, the facility failed to document the changes in the resident's mental health status which required transfers to the hospital, and failed to notify the responsible party of each transfer for one of three resident reviewed (Resident 13). This failure had the potential to result in emotional distress for Resident 13 and Resident 13's responsible party.

Inspectors wroteBased on interview, and record review, the facility failed to provide a notice of bed-hold for one of three residents reviewed (Resident 13) and/or the resident representative, upon transfer to the acute care hospital when Resident 13 was transferred to the acute care hospital on July 7, 2024, and on July 8, 2024. This failure resulted in Resident 13 and Resident 13's respresentative not being aware of the bed-hold policy of the facility. In addition, this failure resulted in the resident not to be aware of his rights to be allowed to go back to the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe environment when a side exit door was propped open and the alarm turned off. This failure had the potential to result in residents assessed to be at risk for elopement leaving the facility without staff being aware.

Inspectors wroteBased on interview and record review, the facility failed to provide the resident or representative a copy of medical records following a written request in an acceptable timeframe, for one of three residents reviewed (Resident 2). This failure had the potential to cause undue concern and anxiety on behalf of the resident and his family member.

Inspectors wroteBased on interview and record review, the facility failed to ensure, for one of two residents, Resident 3 was accepted by the assisted living facility (ALF-a housing for people with disabilities or adults who cannot live independently) before he was discharged . This failure had the potential to result in Resident 3 to be rejected by the ALF and not receive the care he needed. In addition, this failure had the potential to result in unnecessary hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to ensure, for two of five residents, Residents 4 and 5, plans of care were inititated when they were both involved in a resident-to-resident altercation. This failure had the potential to result in Resident 4 and 5's needs to be unmet and the potential for further altercations.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three residents reviewed, Resident 2, received his anti-seizure (seizure- a sudden, uncontrolled electrical activity of the brain) medications for two days. This failure had the potential to reduce the effectiveness of Resident 2 ' s anti-seizure medication. In addition, this failure potentially caused Resident 2 to have a seizure.

Inspectors wroteBased on interview and record review, the facility failed to ensure for, one of two residents, Resident 1, that interventions to reduce falls were evaluated for effectiveness. This failure resulted for Resident 1 to have repeated falls during his stay at the facility which could have resulted in serious injury to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient nursing staff to be able to provide for care and services for the residents of the facility. This failure had the potential to cause delay in the response to residents ' call lights being answered and put residents at risk for falls and accidents. This failure also had the potential for late provision of care or care not being rendered at all.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three residents reviewed (Resident 5) was treated with respect and dignity when a Certified Nursing Assistant (CNA) told Resident 5 callate in Spanish, which meant shut up in English. This failure had the potential for Resident 5 not to feel respected and dignified which could negatively impact the resident's emotional well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the plan of care for two of five residents reviewed (Residents 1 and 4) were updated and revised when: 1. Resident 1 had an elopement (a situation when a resident leaves the facility without authorization) incident on June 3, 2024; and 2. Resident 4 had an elopement incident on June 9, 2024. This failure had the potential to result in harm and injury to Residents 1 and 4, when their person centered care plans had no specific goals, measurable interventions and timeframes to prevent the incidents of elopement.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three residents reviewed (Resident 4) was assessed, monitored, and supervised to prevent elopement (leaving the facility without permission). This failure resulted in Resident 4's eloping from the facility and had the potential to cause injury and harm to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a comfortable and homelike environment was provided for one of seven residents reviewed (Resident 3), when Resident 3's personal belongings were placed in boxes and stored in a closet and were inaccessible to Resident 3. This failure prevented Resident 3 to enjoy her personal belongings and preferred clothing when out for an appointment, and while conducting activities at the facility.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the physician and the responsible party (RP) were notified when one of eleven sampled residents (Resident 10) alleged physical abuse against a facility staff (Certified Nursing Assistant). This failure resulted in the physician not being aware of the alleged physical abuse which delayed the provision of needed medical evaluation and treatment. In addition, the facility's failed to notify the responsible party for Resident 10, has the potential to negatively affect the psychosocial well-being of the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. For Resident 1, an allegation of misappropriation of funds was reported to the State Survey Agency at the mandated time frame (immediately but not later than two hours), when Resident 1 reported money was stolen from his room while he slept. The facility staff was made aware of the alleged theft on May 24, 2024. This failure had the potential to place Resident 1 and other residents at risk from harm and delayed the investigation of an allegation of misappropriation of funds. 2. An allegation of verbal abuse involving two residents (Residents 1 and 8) were reported to the State Survey Agency not later than two hours after the allegation was made. This failure had the potential to result in delayed protection of the residents, investigation of the incident, and implementation of corrective actions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide grooming care, when one of eleven sampled residents' (Resident 9) fingernails and toenails were not kept trimmed. Resident 9 has hemiplegia (paralysis of one side of the body), and hemiparesis (weakness of one side of the body). This failure had the potential to lead to a low self-esteem which could negatively affect the psychosocial well-being of Resident 9.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five residents, (Resident 5), was treated with dignity, when Resident 5's gown was not changed when he was observed with scrambled eggs down the front of his gown. This failure had the potential for Resident 5 to feel dehumanized, (deprived of positive human qualities), and live comfortably.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report an allegation of abuse on April 29, 2024, was reported in a timely manner to the State Agency (SA) as required, for two of five residents reviewed (Residents 9 and 10). This is failure to report abuse within 2 hours of incident may result in a delay in starting an investigation and securing resident safety.

Inspectors wroteBased on observation, interview, record review, the facility failed to ensure an updated staffing information of the total number and actual hours worked by the licensed and unlicensed nursing staff was posted in a prominent place readily accessible to residents and visitors. This failure had the potential for facility to be unable to provide and determine the actual sufficient nursing hours required in the provision of care and services for the residents in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide sufficient nursing staff to be able to provide for care and services for the residents of the facility. This failure had resulted in multiple residents (Resident's 77, 18, 21, 132, 663, 97, 142, and 24) not receiving wound care treatments on multiple days (refer to F686). In addition, this failure caused delays in the response to multiple residents' call lights which had the potential to put residents at risk for falls, accidents, late provision of care or care not being rendered at all.

Inspectors wroteBased on interview and record review the facility failed to initiate a care plan for weight loss, poor oral intake and use of antidepressant for one of two residents, Resident 1. This failure had the potential for Resident 1 not to receive appropriate interventions tailored to her needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement proper infection prevention and control practices when: a. Appropriate State department was not contacted regarding the positive cases, b. Masking was not mandated to control the spread of Covid, and c. Follow up testing was not performed per CDC (Center for Disease Control and Prevention) and CDPH (California Department of Public Health) guidelines. These failures resulted in inadequate source control and monitoring of the facility ' s vulnerable population it cared for.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure five of five sampled residents (A, B, C, D, F) received treatment and care in accordance with professional standards of practice. This failure has the potential to result in negative outcome for these five residents ' physical, mental, or psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there was a sufficient number of nursing staff to provide care for five (Resident A, B, C, D, F) out of six residents reviewed. This resulted in a delay of care to meet the needs of Residents A, B, C, D, and F, which could negatively affect the Residents ' rights, physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview, and record review, the facility failed to ensure pharmaceutical services were provided to meet the needs of a resident when the physician ordered medications were not acquired by the facility timely and available for use, for one of four residents reviewed (Resident 1). This failure had the potential to result in the delay of treatment and care for the resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident representative's rights were respected, for one of four residents reviewed (Resident 4), when Resident 4's resident representative (RR) requested the facility to manage Resident 4 ' s benefit payments (representative (rep)-payee). This failure caused Resident 4 ' s facility payments to go unpaid and had the potential to cause Resident 4 ' s resident representative (RR) to experience undue financial stress.

Inspectors wroteBased on observation, interview and record review, the facility failed to inform the resident of the share of cost (SOC) and the amount of charges for the items and services not covered by Medicare (federal health insurance for anyone aged 65 and older)/Medicaid (federal and state program that gives health coverage to some people with limited income and resources), for one of four residents reviewed (Resident 3). This failure had the potential to result in the resident to not be informed about the potential liability for payment.

Inspectors wroteBased on interview, and record review the facility failed to ensure, for one of four residents reviewed (Resident 1), professional standards of practice were followed when the physician was not contacted for orders for a lung biopsy when requested by Resident 1 ' s Representative (RR) on February 8, 2024. This failure had the potential for care and services for Resident 1 to be delayed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe environment for one of three sampled residents (Resident 2) when Resident 2 left the facility without the staff ' s knowledge. This failure resulted in Resident 2 eloping (leaving a facility without notice) from the facility and had the potential to cause injury and harm to the resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure an appropriate pain management was provided for one of three sampled residents'(Resident 1) complaint of pain to right knee and leg after an altercation with another resident on December 13, 2023. This failure increased the risk for having continuous pain which could impair mobility and function for Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light (devices that produce a tone and light up indicating the location of the call, used by the residents to signal a need for assistance from facility staff) were answered promptly for one of three sampled residents, (Resident 1). This failure increased the potential for delayed nursing and medical management as well as actual unmet care needs.

Inspectors wroteBased on interview and record review the facility failed to ensure services provided met professional standards for one of three sampled residents (Resident 1) when Resident 1 ' s medications were not given on time as ordered by the physician. This failure had the potential to place Resident 1 at risk for delay in treatment medical complications and further decline in their overall physical well-being.

Inspectors wroteBased on interview and record review, for one (Resident 3) of eight residents, the facility failed to ensure weight loss (13 pounds/lbs.) recorded on November 20, 2023, was referred to the physician when it was identified during IDT weight variance meeting on November 24, 2023. The facility failure had resulted for an additional 4 lbs. weight loss a week later on November 27, 2023, when the physician was not notified and interventions were not put in place to prevent and halt further weight loss.

Inspectors wroteBased on interview and record review the facility failed to ensure for one of three Residents, Resident 1 ' s phenobarbital medication (medication to control and prevent seizure- a sudden, uncontrolled burst of electrical activity in the brain that can cause changes in behavior, movements, feelings and levels of consciousness) was made readily available for administration. The facility's failure to make the medication readily available had resulted for Resident 1 to miss one day of Phenobarbital medication.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of five residents reviewed (Resident 1) was free from verbal abuse when the Activities Assistant (AA) called Resident 1 an inappropriate name. This failure had the potential for Resident 1 to experience emotional distress.

Inspectors wroteBased on interview and record review, the facility failed to ensure the admission agreement was honored, for one of three sampled residents (Resident 1). The facility failed to allow Resident 1 readmission to the facility while Resident 1 was on a 7 day bedhold.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the residents with the proper size of briefs (adult diaper-a disposable garment used to absorb urine, usually worn under clothes), for two of five residents reviewed (Resident 1 and Resident 5) when Resident 1 and 5 complained the facility briefs caused irritation to the resident's thighs due to being too small. This failure caused Resident 1 and 5 to purchase their own proper sized adults briefs causing unnecessary expenses to the residents and/or their families.

Inspectors wroteBased on observation, interview, and record review, the facility failed to document a change of condition, for one of five residents reviewed (Resident 1) when Resident 1 had an X-ray (picture of the inside of the body), CT scan (computerized tomography-series of x-rays taken from different angles around the body), and stool sample (laboratory [lab] test used to determine if bacteria and/or virus are detected in the stool) ordered by the physician with no documented indication. This failure had the potential for confusion of care to occur for Resident 1.

Inspectors wroteBased on interview, and record review, the facility failed to ensure a physician ' s order for stool sample (laboratory [lab] test used to determine if bacteria and/or virus are detected in the stool) was completed timely, for one of five residents reviewed (Resident 1). This failure had the potential to result in the delay of diagnoses and necessary treatments for Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards for two residents reviewed for accidents, when Resident 1 hit Resident 2 with a broom left out by housekeeping staff. This failure resulted in Resident 2 being physically hit and could potentially result in serious injuries.

Inspectors wroteBased on interview and record review, the facility failed to provide and document sufficient preparation and orientation to ensure a safe and orderly discharge from the facility for two of six residents reviewed (Resident 1 and 2), when the residents were discharged to an undisclosed location, and there was no documentation in Resident 1's record of diabetic teaching and diabetic supplies being given to Resident 1 prior to discharge. This failure resulted in the unsafe discharge for Resident 1 and 2 back into the community.

Inspectors wroteBased on interview, and record review, the facility failed, for four of six residents reviewed (Resident 1, 2, 4 and 5), to maintain accurate medical records in accordance with accepted professional standards and practice when the residents' discharge was not documented clearly. This failure could increase the potential for confusion to occur in the safe and orderly discharge of the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure, for one of six residents (Resident 1), an effective training and education regarding insulin (medication to control high blood sugar levels) administration and durable medical equipment needed to perform fingerstick blood sugars to monitor Resident 1's diabetes (abnormal sugar in the blood) were provided prior to discharge. This failure had the potential for Resident 1 to experience hyper and/or hypoglycemic (blood sugar levels are too high or low for the body to function) episodes which could be life threatening.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident was treated with dignity and respect, when a Restorative Nursing Assistant (RNA) forcefully fed Resident 1. This failure resulted in not ensuring residents' rights to be treated with dignity and respect and could potentially result in negative physical or psychosocial outcomes, such as choking, or changes in mood and/or behavior.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional and sanitary environment for the residents, staff and public, when one of 15 residents' (Resident 15) room had a leak on the ceiling. In addition, there was an opened ceiling adjacent to room [ROOM NUMBER]. This failure could result for water from the rain to actively drip down and could leave puddles causing accidents to residents and staff, and a potential for fungal spores to be dispersed in the environment.

Inspectors wroteBased on observation, interview, and record review, to provide phenobarbital medication (to control and prevent seizure- a sudden, uncontrolled burst of electrical activity in the brain that can cause changes in behavior, movements, feelings, and levels of consciousness) on August 11, 12, and 13, 2023, in accordance with the physician order for one of three sampled residents (Resident 1). The facility failure to administer Resident 1's Phenobarbital medication had the potential for the resident to experience a seizure and complication.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the routine phenobarbital medication (medication to control and prevent seizure- a sudden, uncontrolled burst of electrical activity in the brain that can cause changes in behavior, movements, feelings and levels of consciousness) was made readily available for administration, for one (Resident 1) of three residents. The facility failure to make the medication readily available had resulted for Resident 1 to missed three days of Phenobarbital medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call lights (devices that emit a tone and light up indicating the location of the call, used by the residents to signal a need for assistance from facility staff), were plugged in and operational, when three out of five residents (Residents 1, 2, and 4), who required assistance from staff with activities of daily living (ADLs), verbalized their concerns of facility staff not answering their call lights and/or attending to their needs in a timely manner. This failure had the potential for delayed medical management and unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure skin redness was identified and accurately documented, water was offered and at bedside, and the residents were offered get out of bed, for one of five residents reviewed, (Resident 1), when: 1. Resident 1 had redness and irritation to her left neck that was not identified or assessed; 2. There was no water pitcher or water observed at Resident 1's bedside; and 3. Resident 1 stated she would like to go to activities and/or the dining room for meals but was not assisted up. This failure had the potential to result in the delay of the necessary care and treatment needed for Resident 1 and had the potential for Resident 1 to experience dehydration, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to address the individualized needs related to substance use behavior, (SUB - continually using drugs or alcohol even though it is causing or adding to physical or psychological problems), for seven of 13 residents reviewed, (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 8, and Resident 9), who had history of substance use prior to admission and had been suspected of illegal drug use while at the facility. In addition, the facility failed to increase monitoring and supervision of the seven residents suspected of illegal drug use as well as the 136 residents not involved. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to exercise reasonable care for the protection of the resident's property from theft or loss to occur, when: 1. Resident belongings were not inventoried and accurate for 3 out of 14 residents (Residents 1, 3, and 7), and; 2. Resident 7 left the facility against medical advice (AMA) and his belongings were disposed of before Resident 7 could retrieve them. This failure resulted in the violation of the resident's rights of having a safe environment, ensuring the protection of personal property and/or belongings and had the potential to cause emotional distress for the residents and/or family.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report an allegation of illegal drugs paraphernalia, and illegal drug use in the facility to the California Department of Public Health Licensing and Certification, (CDPH L&C) within 24 hours. This failure had the potential for continued use and abuse of illegal drugs in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a diagnostic procedure was provided in a timely manner, for one of fourteen residents reviewed (Resident 3), when an x-ray (procedure used to create images of the structures inside the body, used to assess for broken bones) order was not obtained from the physician, when Resident 3 complained of a sore wrist with swelling and redness after a fall on August 27, 2023. This failure had the potential for the delay in the treatment and care for Resident 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's bed was in safe working condition for one out of fourteen residents reviewed (Resident 3), when Resident 3's right upper side rail was broken on his bed. This failure resulted in Resident 3 falling from his bed to the floor when the side rail broke and had the potential for Resident 3 to sustain further injury when the bed rail was not repaired timely.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) were allowed readmission to the facility following hospitalization. The resident was not permitted to return to the facility since the resident was found to be positive of Candida Auris (a type of yeast that can cause severe illness and spreads easily among patients). The resident was not re-admitted back to the facility until August 4, 2023. This failure had resulted for the resident to have an unnecessary stay at the hospital from [DATE] to August 4, 2023.

Inspectors wroteBased on observation, interview, and record review, the facility failed, for four of 11 employees reviewed to ensure infection control policy and procedures were followed when: 1. Certified Nursing Assistant (CNA) 1 and Licensed Vocational Nurse (LVN) 1 failed to change their N95 Respirator masks (type of respirator that protects both resident and staff from the transfer of microorganisms and help prevent transmission of infection) after exiting the room of a resident who was infected with the Covid-19 virus (a highly infectious respiratory virus) and entering a different resident room. This failure had the potential to increase staff and resident exposure and transmission of the Covid-19 virus resulting in illness. 2. [...]