Rocky Point Care Center

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure one of four residents sampled for abuse, (Resident 1's) right to remain free from verbal abuse by Certified Nursing Assistant A (CNA A), when CNA A came to work under the influence of alcohol, acted erratically, and intimidated and yelled at Resident 1. This failure caused Resident 1 to feel frightened and concerned about retaliation from CNA A.A review of Resident 1's admission record indicated Resident 1 was admitted in 06/26, with diagnosis of Thoracic Vertebral Compression Fracture (occurs when a vertebral body in the middle or upper spine collapses, typically due to bone thinning or trauma, such as a fall). [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure resident-centered care and services were provided, as ordered, for one of two sampled residents (Resident 2), requiring 1:1 (one-to-one) close supervision, when Patient Companion A (PC A) had fallen asleep during his shift, and Resident 2 was found by Licensed Nurse B (LN B) in a dangerous and vulnerable position with her chest and torso facing upwards and sideways across the bed, and with her legs hanging off of the bed and onto the floor. This failure to provide continuous supervision, as ordered, put Resident 2 at risk for slipping or falling which could result in a serious injury such as a fracture or head trauma. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide written notices of bed-hold policies for two of three sampled residents (Resident 1 and 2) wo were transferred from the facility. This failure placed the two residents at risk for unlawful discharge from the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to readmit one of three sampled residents (Resident 1) after hospitalization, referencing prehospitalization behaviors despite no change in Resident 1's health care needs. This finding resulted in the resident being transferred to another skilled nursing facility after hospitalization, further away from family who could advocate for his needs. This had the potential to result in Resident 1 experiencing unnecessary disruption in his care, emotional distress, and a lack of continuity in treatment and services.

Inspectors wroteBased on observation, measurement and interview, the facility failed to ensure resident bedrooms met the minimum required 80 square feet of living space per resident for 23 out of 31 resident rooms. This failure decreased the facility's potential to ensure residents' were provided a comfortable living environment to support the dignity, privacy and safe mobility within the room.

Inspectors wroteBased on observation, interview, and record review, the licensed nurses failed to ensure the medication rate was below five percent when five errors were observed during 34 medication passes, which resulted in a 14.71% error rate. This failure decreased the facility's potential to ensure medication was administered as ordered by the physician and decreased the expected efficacy of the medication. (Cross-reference F760)

Inspectors wroteBased on observation and interview, dietary staff failed to ensure palatability and nutritive value for 60 residents who were served food from the kitchen during the lunch meal on 3/11/26 when foods were held on the steam table for over 1.5 to 2 hours and the test tray of purred food and vegetables was found to be gummy and bland. These failures decreased the facility's potential to prevent weight loss and malnutrition among residents.

Inspectors wroteBased on observation, interview, and record review, the nursing and maintenance staff failed to ensure respiratory equipment was clean for four residents (Resident 30, 26, 42, 58) out of seven sampled residents when the oxygen concentrator (a medical device that provides supplemental oxygen to people with breathing-related conditions by pulling in ambient air, filtering out nitrogen, and delivering purified oxygen) in the resident's rooms had visible dust and debris in the vents and needed a filter change. This failure decreased the facility's potential to prevent bacteria and debris from directly entering the resident's lungs, placing them at risk for infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure licensed nurses did not administer oxygen per physician's orders for two residents (Resident 67 and Resident 58) of nine sampled residents when:Resident 58 did not have the ordered amount of oxygen being delivered and,Resident 67 did not have a humidifier attached to the oxygen concentrator (a medical device that provides supplemental oxygen to people with breathing-related conditions by pulling in ambient air, filtering out nitrogen, and delivering purified oxygen)These failures had the potential to place residents at risk for inadequate oxygenation and a potential decline in respiratory status.

Inspectors wroteBased on observation, interview, and record review, the facility's Interdisciplinary Team (a collaborative group of health care professionals who provide comprehensive, patient-centered care) failed to initiate a comprehensive care plan regarding Resident 46's hearing impairment and ensure hearing services were provided for Resident 46 of two sampled residents .This failure decreased the facility's potential to assist residents in gaining access to necessary care regarding her hearing impairment.

Inspectors wroteBased on observation, interview, and record review, the licensed nurses failed to ensure pharmaceutical services met the needs of each resident when:The facility did not sign delivery receipts for narcotic and non-controlled medications on 3/1/26, 3/2/26, 3/6/26 to 3/8/26, and 3/10/26 for a combined total of 1,036 doses. Licensed Nurse (LN) 1 left medications at Resident 44's bedside. These failures decreased the facility's potential to ensure safe and secure medication management, increased the risk of medication loss or diversion (the illegal transfer of prescription drugs to be sold for profit or for personal abuse) and decreased the potential for medications to be safely administered among residents.

Inspectors wroteBased on observations, interviews and record review, the licensed nurses failed to ensure residents were free from significant medication errors for three residents (Resident 6, 32, and 8) of 10 sampled residents when:1. Residents 6 and 32 were not administered insulin pen injections as per manufacturer's instructions and;2. Resident 8 was not administered rifaximin (a medication used to kill bacteria that produces ammonia in the intestines and prevents toxins from reaching the brain and causing confusion or severe personality changes) for 36 doses. These failures placed the residents at risk for avoidable adverse clinical outcomes including uncontrolled blood glucose levels and exacerbation of liver disease.

Inspectors wroteBased on interviews and record reviews, the facility failed to protect Resident 1's right to be free from verbal abuse when Resident 2 verbally abused Resident 1 by yelling profanities and calling her an expletive. These failures decreased the facility's potential to prevent mental anguish and emotional distress among residents.

Inspectors wroteBased on interviews and record reviews, the facility failed to report an allegation of verbal abuse within two hours to the California Department of Public Health (CDPH) for one resident (Resident 1) of two sampled residents when Resident 2 yelled and threated Resident 1 on 12/25/25, 12/31/25, and 1/7/26. This failure decreased the facility's potential to ensure residents were protected against abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and serve food in a safe and sanitary manner when:1. Muffins with mold (mold is a type of fungus that can grow on food) were served on breakfast trays, and six residents consumed them.2. Dry goods were improperly stored when expired cocoa powder was in the storage area, a gravy packet had leaked, chocolate chips were in an open plastic bag without a date when it was opened.3. Deli meat in a refrigerator was ten days past its use by date.4. Frozen pancakes and frozen egg rolls did not have a date when they were received.5. Trash cans were uncovered during tray line (name of process where food was served on resident's plates). This failure had the potential to cause food-borne illness in 64 of 64 vulnerable residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was stored, prepared and served safely in accordance with professional standards of food service when:1. Soiled equipment was observed in a food prep area;2. The floor was noted to have solid food debris, built up dust, and dirt underneath the sink and behind the oven;3. Kitchen staff did not monitor the tray line food temperatures; and,4. Kitchen staff did not use facial hair nets. These failures posed the risk for food borne illnesses for 57 of 57 residents who resided in the facility and consumed food prepared in the kitchen.

Inspectors wroteBased on observation and interview, the facility failed to create a homelike environment for a census of 57 residents when walls in multiple residents' rooms were damaged and carpeting throughout the facility was worn and stained. These failures decreased the facility's potential to ensure residents were provided a safe, clean, comfortable, homelike environment to support their overall well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect one resident (Resident 1) of three sampled residents from physical abuse by Resident 2, when Resident 2 deliberately placed his hands on Resident 1 ' s chest and pushed him which caused Resident 1 to fall during an argument over a television (TV) channel inside their room. This failure resulted in a skin tear (a wound caused by direct force which separates the skin ' s layers) and an abrasion (a scrape) on Resident 1 ' s left forearm.

Inspectors wroteBased on interviews and record reviews, the facility failed to: 1. Ensure staff were aware of whom to report abuse allegations and the timeframe for reporting abuse allegations. 2. Report an abuse allegation timely, when two out of two abuse allegations (Residents 36 and 15's altercation and Resident 221's alleged abuse) were reported more than two hours later after the abuse allegation was made. These failures could lead to ongoing abuse and could result in residents feeling scared, upset, and frustrated.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the nurses were following the Physician's Order for pain medication for one out of two sampled residents (Resident 37), when the nurses administered a pain medication that was not appropriate for the pain level Resident 37 was reporting. This failure could result in unrelieved pain, worsened pain, impaired mobility, and residents feeling upset, angry and frustrated.

Inspectors wroteDuring an observation, interviews, and record reviews, the facility failed to ensure residents were served food items that were palatable and at the right temperature, for four out of four sampled residents (Residents 30, 6, 38, and 43). These failures could put the residents at risk for loss of appetite, frustration, malnutrition (condition that develops when the body is deprived of vitamins, minerals, and other nutrients it needs to maintain healthy tissues and organ), and weight loss.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure refrigerated items in the kitchen were clearly labeled, easily identified, and dated. These failures could compromise food safety and could lead to residents getting sick with gastrointestinal (GI, made up of organs that food and liquids travel through when they are swallowed, digested, absorbed) illness such as Salmonella (an infection with Salmonella bacteria that causes diarrhea- passage of three or more liquid stools, fever and stomach pains), Gastroenteritis (stomach flu) and food poisoning (an illness caused by eating contaminated food).

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure: 1. Perishable food items from home, stored in the refrigerator for the residents, was dated and labeled with the resident's name. 2. Staff were aware on the facility's policy on when to discard refrigerated food items from home. These failures could lead to cross-contamination, and unsafe and unsanitary storage of food, which were a safety risk that could lead to accidental ingestion of expired food items and food being served to the unintended residents.

Inspectors wroteBased on observations and interviews, the facility failed to ensure: 1. Hand hygiene (HH, hand-washing with water and plain or antiseptic soap or rubbing hands with an alcohol-based product in the form of a gel to clean hands and remove dirt, bacteria, and viruses) was offered and provided, for seven out of seven sampled residents (Residents 18, 29, 28, 10, 54, 1 and 14). 2. Utensils were cleaned thoroughly and stored under sanitary conditions, when there was a plate on the plate warmer noted with dried food, and kitchen utensils were not properly dried prior to storing in the drawer. These failures could lead to residents getting sick with infection if they were not offered or provided HH before and after meals. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide an explanation for not providing a SNF ABN (Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage) and a NOMNC (Notice of Medicare Non-Coverage), to one of three residents (Resident 220), prior to discharge from the facility. This failure had the potential to prevent the resident from making an informed decision about their discharge from the facility.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure : 1. Staff were aware of the Baseline Care Plan (BCP, an initial person-centered care plan, completed within 48 hours of admission, that provides instructions for the care of the residents) completion timeframe. 2 .The BCP was completed timely for three out of three sampled residents (Residents 54, 60 and 28). These failures had the potential to lead to delayed or omitted care, missed medications or treatments, medical complications, and deconditioning.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure that three of eight sampled residents, Resident 2, 38, and 51, received care and services that met their physical, mental, and emotional needs, and according to the facility's policy and procedure on answering call lights and repositioning, when these residents had to wait for a long time before they were assisted after pushing their call light buttons to request for assistance from their aides. These failures had the potential to result in skin breakdown, when the residents were left soiled in urine or feces (the material in a bowel movement), or when residents were left in a certain position for a significant amount of time and could also affect their emotional well-being.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure residents were not receiving food items that they did not like, for one out of three sampled residents (Residents 117). This failure could result in Resident 117 not eating the food and could put Resident 117 at risk for weight loss and inadequate nutrition.

Inspectors wroteBased on observation and interviews, the facility failed to ensure the kitchen floor was in good repair, when the linoleum (a hard, washable floor covering formed by coating burlap or canvass with linseed oil, powdered cork, and resin, and adding pigments to create the desired colors and patterns) floor on multiple parts of the kitchen area (by the gas stove, door leading to the hallway, the sink) was coming apart and its edges were raised off the floor. This failure could be an infection control issue due to difficulty in ensuring the floor was adequately cleaned and sanitized. This failure could also be a safety issue due to being a trip hazard.

Inspectors wroteBased on observations and interviews, the facility failed to ensure the kitchen was free of flies. This failure posed a health risk, as flies carry diseases such as Salmonella (a group of bacteria that can cause diarrhea-passage of three or more liquid stools, in humans) and Cholera (an infectious disease that causes severe watery diarrhea), which could contaminate the food stored, prepared and served to the residents in the facility.

Inspectors wroteBased on record review and interview the facility failed to follow physician orders to get blood work done for Resident 1 which would have included Resident 1's blood sugar level. This failure to have blood work drawn caused the facility to not identify and treat Resident 1's diabetes, resulting in elevated blood sugar levels that interfere with healing processes.

Inspectors wroteBased on observation and interview, the facility failed to provide a safe, clean, comfortable, and homelike environment to two of two residents (Residents 1 and 2) by not ensuring their room was free of flies. This failure resulted in Residents 1 and 2's well-being and sleep being disturbed by the flies.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the menu as posted when residents on a pureed diet were not served the rice dish, and wheat rolls were not served when on the menu. This resulted in residents not getting a full meal and missing an opportunity to have whole grain bread.

Inspectors wroteBased on observation, interview and record review, the facility failed to honor residents' request for more variety of fruits and seasonal fruits when the dietary department only ordered and kept in stock oranges and bananas. This failure caused residents to eat the same fruit repeatedly with no variation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep the floors clean under the refrigerators and freezers in the kitchen. This failure could potentially attract vermin in the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to implement its Policy and Procedure on filing grievances/complaints by residents when: 1) Residents did not know where to get the grievance forms. 2) Residents did not know how to file grievance when their right were violated. 3) Residents were in fear of discrimination and fear of retaliation from staff when they voiced their concern or grievance. These failures had the potential to result in violation of resident's rights, maltreatment, neglect, and unresolved grievances.

Inspectors wroteBased on interviews and record reviews, the facility failed to follow it policy and procedure to provide a copy of transfer/discharge notice to the representative of the Office of the Long-Term Care (LTC) Ombudsman for two out of three sampled residents (Resident 10 and Resident 5). These failures could have prevented the Ombudsman to advocate for Resident 10 and Resident 5 and potentially resulted in inappropriate transfers/discharges from the facility.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to develop comprehensive person-centered care plans to 5 of 18 sampled residents (Residents 103, 5, 23, 16, and 25), that meets the resident's medical, nursing, and mental and physical needs, that were identified in their comprehensive assessments. These failures had the potential to negatively impact Resident 103, 5, 23, 16 and 25's quality of life, as well as the quality of care and services they received.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that medications were given timely for eight residents (Resident 46, Resident 30, Resident 9, Resident 33, Resident 7, Resident 18, Resident 35, and Resident 17). This failure could result in residents having increased pain or anxiety due to delay in receiving their medications on time.

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve a flavorful pureed food to residents on a pureed diet. This failure resulted in residents on a pureed diet being served a bland food.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the physician was made aware of a significant weight loss for one of one sampled residents (Resident 27). This failure could result in continuous weight loss and harm to Resident 27.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a prescribed psychotropic (a drug that affects brain activities associated with mental processes and behavior) medication had a documented, specific diagnosis with adequate monitoring for effectiveness for one of five residents sampled for unnecessary medication review (Resident 23). This failure potentially resulted in Resident 23 taking an unnecessary medication.