Rossmoor Post Acute

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain essential mechanical equipment in safe operating condition when The facility did not ensure four of four facility ice machines were cleaned, sanitized, and maintained according to manufacturer instructions. This deficient practice could expose residents to contaminated ice and increase their risk of infection, illness, hospitalization, or other adverse health outcomes for 151 of 151 residents who were residing in the facility and potentially use ice form ice machines. During a concurrent observation and interview on 7/7/26 at 10:20 a.m., with the Facilities Director (FD), FD stated he cleaned each facility ice machine every four months. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure respiratory therapy equipment was changed weekly for two of five sampled residents (Residents 70 and 161) who received oxygen therapy. This failure had the potential to contribute to the increased risk of infection and dry nasal passages, which could cause extreme discomfort for Resident 70 and 161. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 7) was free from unnecessary psychotropic drugs (medications that are capable of affecting the mind, emotions, and behavior) when Resident 7 had no rationale (reason) for continued use of PRN Lorazepam beyond 14 days (PRN or pro re nata [a Latin phrase], meaning as needed, or as necessary and Lorazepam is a psychotropic medication used to treat anxiety). These failures had the potential to not promote or maintain Resident 7's highest practicable mental, physical, and psychosocial well-being. During a review of Resident 7's Facesheet indicated that the resident was admitted to the facility on [DATE] with diagnoses which included dementia (a decline in mental ability severe enough to interfere with daily life). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a copy of the discharge notice was sent to the Long-Term Care (LTC) Ombudsman for one of three sampled residents (Resident 144). This failure had the potential for the LTC Ombudsman not to be able to advocate for the resident in protecting their rights from inappropriate transfer and discharge. During an interview on 7/8/26 at 12:00 p.m., with the LTC (Long Term Care) Ombudsman (a trained advocate who protects the rights, health, and quality of life for residents living in nursing homes, assisted living facilities ), LTC ombudsman stated the facility did not notify them about Resident 144's discharge or the new location on 7/2/26, . LTC Ombudsman stated they learned about the resident's discharge from another source rather than from the facility. [...]

Inspectors wroteBased on observation, interview and record review, facility failed to provide timely nursing assessment and evaluation to one of three sampled residents (Resident 150) after an unwitnessed fall on 3/21/26. This failure had the potential to result in delayed identification of changes in condition, delayed nursing interventions and treatment, worsening conditions, hospitalization and decline in Residents 150's health status. During a review of Resident 150's admission record indicated Resident 150 was admitted to the facility on [DATE] with diagnoses of history of falls and difficulty in walking. [...]

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the person designated as the position responsible for the day-to-day management of the department was qualified per state regulations. This failure had the potential to negatively affect the health and well-being of 151 residents who received food prepared in the kitchen. State of California Title 22 Section 72333 describes dietetic service as a department that is organized, staffed and equipped to ensure food service to patients is safe, appetizing and provides for their nutritional needs. According to the California Code, Health and Safety Code - HSC S 1265.4, a licensed health facility shall employ a full-time, part-time, or consulting dietitian to supervise the provision of dietetic services. [...]

Inspectors wroteBased on observation, interview and facility document review, the facility failed to provide mechanically altered foods according to the menu for the Soft and Bite Sized (SB6) Diet (a diet designed for those who have difficulty chewing or swallowing but can safely eat soft foods). This failure had the potential to not meet the resident's nutritional needs for the 16 of 151 residents (Residents 15, 16, 18, 21, 48, 52, 57, 84, 87, 93, 110, 116, 120, 122, 151, 186) who received an SB6 diet. During an interview on 07/07/2026 at 11:00 AM with [NAME] 1 (CK1) in the kitchen during meal preparation of Beef Rib Bites with Teriyaki Sauce, [NAME] stated that he would be using the same sized beef for the Regular diet and the SB6 diet. [...]

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to prepare, and serve food under sanitary conditions when, staff were observed using disposable face masks as hair coverings and facial hair coverings. These deficient practices had the potential to result in contamination of food, and compromised food service sanitation for all residents who were eating food, prepared by the facility's kitchen's staff. During observations on 07/07/26 at 10:15 a.m., saw kitchen staff using disposable face masks as facial hair coverings while working in food preparation areas. Hair was not fully restrained or covered. During interview on 07/07/26 at 10:24 a.m., the Dietary Manager stated staff had been observed using disposable face masks as facial hair coverings. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary handling and consumption of food brought into the facility by family or visitors for one of three sample selected residents (Resident 139), when the facility did not provide instructions to Resident 139's visitors regarding safe food handling practices and did not ensure food brought from outside sources was managed safely in accordance with posted dietary precautions. This deficient practice could result in Resident 139 being exposed to foodborne illness or other preventable harm due to unsafe handling and consumption of food brought in by visitors. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper disposal and containment of refuse when the facility's outdoor garbage compactor was observed with a large mound of trash bags placed directly on the ground. The refuse was not contained in any waste receptacle and was not secured with a covered lid. The recycling dumpster was observed with lid not covering the container. Overflowing cardboard boxes and other recyclable materials were placed on the ground next to the recycling dumpster. These deficient practices had the potential to attract rodents and insects and create environmental contamination hazards in areas adjacent to residents care services. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to report a right wrist fracture (broken bone) sustained by one of three sampled residents (Resident 150), to the State Agency as required, when Resident 150 was sent to the emergency department on 3/29/26 for evaluation of right wrist pain, where an x-ray confirmed fractures of the right radius (thumb side of the wrist) and ulna (pinky side of the wrist). This failure could resulted in unaddressed causes of injury, missed corrective actions, and continued risk of harm to residents because required oversight, investigation, and prevention measures would not be initiated.

Inspectors wroteBased on interview and record review, the facility did not ensure that the binding arbitration agreement was explained to and understood by either the resident or the resident's personal representative for Residents 26, 38,187,188. This deficient practice has the potential result in residents (Residents 26, 38,187,188.) and/or resident representatives not being aware of, or fully understanding, the implications of signing an arbitration agreement. During an observation on 7/9/26 at 8:55 a.m., Resident 26 was observed lying in bed with the resident's daughter present at the bedside. The daughter is Resident 26's personal representative. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control prevention practices when:1. Resident oxygen tubing (colorless, odorless, tasteless gas that is essential for effective breathing) for Resident 3 and Resident 72 was not secured and off the floor.2. Visitors were allowed into Resident 72' s room without wearing personal protective equipment (PPE- specialized gear and clothing worn by healthcare workers and residents to create a barrier against infections materials).3. Resident 88's oxygen was stored in the bathroom.4. Three pill crushers were dirty. These failures had the potential for cross contamination and spread of infections among for Residents who were residing in the facility. 1. [...]

Inspectors wroteBased on observation, interview, and record review, facility failed to ensure one out of three sampled residents (Resident 1) received adequate discharge planning and communication regarding a facility-initiated discharge. This failure resulted in Resident 1 experiencing fear, distress, and uncertainty regarding discharge plans. During a review of facility's document titled, admission Record, printed 6/8/26, Resident 1 was originally admitted to the facility on [DATE] with multiple diagnoses including polyneuropathy (a nerve disease that can cause pain, discomfort, and mobility difficulties) and chronic pain. During a review of facility's document titled, Brief Interview for Mental Status, (BIMS, an assessment for mental status), dated 3/4/26 for Resident 1, the BIMS indicated Resident 1 had a score of 15 out of 15, indicating no impaired cognition (intact mental status). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure it kept accurate records of controlled medications (medication with a potential for abuse) as evidenced by: 1. The facility failed to ensure, for Residents 1-7, the scheduled (controlled medication, narcotic) medication system was complete (all documents available) and accurate (information matched). The record system included Shipping Manifests (pharmacy delivery receipt), Controlled Substance Accountability Sheets (CDR, Controlled Drug Record), Medication Administration Records (MAR, record of medication administration) and destruction logs. The facility records were incomplete. The facility records were inaccurate. These failures had the potential to result in undetected loss and diversion of scheduled medications. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff followed infection control practice when:1. [NAME] 1 did not adhere to hand hygiene practice while checking temperatures of ready to eat foods,2. non-kitchen staff entered the kitchen without performing hand hygiene to get fruit, and3. [NAME] 1 contaminated the dinner tray line with raw fish. This failure placed residents in the Medbridge unit at risk of foodborne illness which had the potential for death.1. During an observation on 8/27/25 at 4:21 p.m., [NAME] 1 was at the tray line wearing gloves while using the temperature probe to measure food temperatures. After taking the temperature of pureed potato, [NAME] 1 adjusted their glasses with their gloved hand, then removed an alcohol wipe from their pants pocket with the same gloved hand. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to inform a Resident's responsible party regarding change of condition and transfer from facility to acute care hospital for one of three sampled Residents (Resident 1). This failure resulted in Resident 1 being transferred to an acute care hospital alone, without notice to their responsible party. During a record review of admission record, printed on 4/7/26, Resident 1 was admitted on [DATE]. Under 'Contacts', the Resident's daughter was listed as emergency contact #1, responsible party. During a record review of Resident 1's Minimum Data Set (MDS, an assessment used to guide care) dated 12/23/25, indicated Resident 1's Brief Interview for Mental Status (BIMS, an assessment tool used to assess mental status) score was 2 out of 15, and indicated Resident 1's cognition was severely impaired. [...]

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure a preadmission screening and resident review (PASARR) was accurately completed for 1 (Resident #105) of 3 sampled residents reviewed for PASARR requirements.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control was maintained to prevent the development and/or transmission of communicable diseases and infections for 1 (Resident #313) of 8 residents reviewed for infection control. Specifically, the facility failed to dispose of an intravenous (IV) catheter used to administer IV fluids to Resident #313.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication bubble pack labeled with resident information was kept secured and confidential when it was found on top of a treatment cart, in a hallway, for public view and access. This failure resulted in a resident's confidential medical information compromised and could potentially impact 154 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate safety measures and adequate supervision to prevent one of three residents (Resident 1) from rolling out of bed and falling on the floor during after-shower care. The failure to provide sufficient staff or adequate measures to prevent a dependent resident from rolling off the bed during Activities of Daily Living (ADL, the basic self-care tasks an individual does on a day-to-day basis) care/after-shower care, resulted in Resident 1 being transported to the emergency department for evaluation after the fall, caused a seven centimeter (cm) laceration to the right forehead, a brief loss of consciousness, and a contusion (a bruise or skin discoloration due to injury to soft tissue) of right ankle.

Inspectors wroteBased on interview and record review, the facility failed to accurately assess one of two sampled residents (Resident 1) on the Minimum Data Set (MDS, an assessment tool used to direct care). This failure resulted in an inaccurate reflection of Resident 1's current health condition which had the potential for Resident 1 to not receive the person-centered care that Resident 1 deserved.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident received the necessary respiratory care in accordance with professional standards of practice when facility failed to provide in a timely manner, the missing connector for the appropriate-sized BIPAP (bilevel positive airway pressure, a machine used to treat sleep apnea [a sleep-related breathing disorder]) mask used by one of two sampled residents (Resident 1). This failure resulted in Resident 1's inconvenience, discomfort, several nights of interrupted sleep, skin breakdown to nose bridge (related to use of unfit, temporary BIPAP mask), anxiety, and mood swings. This failure also had the potential to result in serious harm and potential death to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have oxygen safety signage posted on Resident 1 ' s room as Resident 1 used an oxygen concentrator (a portable medical device used to deliver oxygen to those who have a condition that causes or results in low levels of oxygen in their blood). This failure had the potential of not having safety precautions in place necessary to care for Resident 1 who required oxygen use.

Inspectors wroteBased on interview and record review, for one of three sampled residents (Resident 1), the facility failed to ensure a suspicion of sexual abuse, including injuries of unknown origin, was reported to appropriate authorities within the required regulatory timeframe when the Ombudsman received a telephone call from the facility ' s Master of Social Work (MSW) on 2/20/24, at 3 pm., regarding a concern that had been brought up by Certified Nursing Assistant 1 (CNA 1) during Resident 1 ' s Care Conference. This failure resulted in the facility's ability to ensure a complete investigation was initiated timely and ensure interventions were initiated to protect Resident 1 as well as all other residents of the facility, from protection from abuse.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) had adequate services to improve or maintain mobility when Resident 1 was discharged from physical therapy services after seven days out of a 60 day physical therapy plan and did not have recommendations at physical therapy service discharge to the physician or nursing staff to maintain or improve mobility. This failure placed Resident 1 at risk of impaired mobility and falls.

Inspectors wroteBased on interview and record review, the facility failed to ensure ongoing nursing assessments for one of three residents (Resident 1) involving: 1. admission Evaluation did not include skin condition of buttock area that had Mepilex (absorbent foam dressing) for protection. 2. When pressure injury was evaluated, Pressure Ulcer Report was not completed until four days after admission and Skin and Wound Evaluation Report was completed after an additional three days. 3. Care plans for rashes and pain were not personalized for Resident 1. 4. Treatment Administration Record (TAR) did not have entries for nine tasks related to skin monitoring and wound care. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all staff wore the proper personal protective equipment (PPE, protective clothing, gloves, face masks, goggles and other garments used to protect the wearer's body from injury or infection) required during the facility's COVID-19 (coronavirus disease 2019, a sickness caused by a virus called severe acute respiratory syndrome coronavirus 2) outbreak when the Receptionist wore a surgical mask (a loose-fitting disposable device that creates a physical barrier between mouth and nose of wearer) instead of the required N95 mask (Non-0il with 95% efficiency, a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles). This deficiency had the potential to place residents, visitors, and other staff at risk for serious respiratory illnesses.

Inspectors wroteBased on interview and record review, the facility failed to establish criteria for registered nursing staff to follow for assessment and determination of irreversible death for one of two sampled residents (Resident 1). This failure resulted in Registered Nurse 1 (RN 1) using her personal judgement to assess Resident 1 as dead, instead of immediately calling 9-1-1 for emergency medical services or starting cardiopulmonary resuscitation (CPR, any medical intervention used to restore blood circulation or breathing functions that have ceased) as per Resident 1's physician order to provide full emergency medical treatment in the event Resident 1 stopped breathing, or Resident 1's heart stopped beating. This failure had the potential to result in residents being denied life-saving measures in the event death was reversible.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three of three sampled residents (Resident 47, 1 and 21) were provided privacy when staff did not draw the curtain during wound care for Residents 47 and 1, and Resident 21's Foley catheter bag (a urine drainage bag that collects urine. The bag is attached to a catheter (tube) is inside the bladder) was not covered and was visible. This failed practice had the potential to jeopardize Residents 47, 1 and 21's dignity.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure four of nine sampled residents (Residents 488, 39, 633, and 8 received showers, bed baths and nailcare when Residents 488, 633, and 39 did not receive timely showers and Residents 8 and 39 did not receive nail care. This failure placed residents at risk for getting infections from lack of proper hygiene, injuring themselves with long fingernails, and compromising residents' physical and psychosocial wellbeing.

Inspectors wrote2. During a review of Resident 633's admission Record Report printed on 11/28/22, the record indicated Resident 633 was admitted to the facility on [DATE]. During a record review of Resident 633's Minimum Data Set, dated 11/16/22, the assessment indicated Resident 633 had a BIMS score of 14 out of 15 and indicated intact mental status. During a concurrent observation and interview on 11/28/22, at 10:43 a.m., Resident 633 was sitting at the edge of the bed and stated, Both my legs are swollen, and they burn and [NAME], for two weeks; no one has come in to help me. During a concurrent observation and interview on 11/28/22, at 12:13 p.m., Minimum Data Set Coordinator (MDSC, a Registered Nurse responsible for conducting the resident assessments) assessed Resident 633's legs and stated Resident 633 had 2+ pitting edema. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. Medications were administered according to physician's orders for 1 of 30 sampled residents (Resident 639); 2. Controlled medications awaiting final destruction were securely stored; 3. Random controlled medication use audits for four of five residents (Residents 3, 11, 57, and 442) were not reconciled. The medications were signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but not documented on the Medication Administration Record (MAR) to indicate they were given to the residents, or documented in the MAR and not signed out of the CDR; and 4. Physician was notified of missed doses of anti-seizure medication for 1 of 30 sampled residents (Resident 102) placing the resident at risk for seizures. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure pharmacy storage and labeling procedures were followed when: 1. Medication refrigerator (#) temperature was not monitored and recorded twice daily; 2. Expired medications in the medication refrigerator were not discarded; 3. Expired medications in the medication carts were not discarded; 4. Resident 90's medication was not labeled; 5. Treatment material was left unattended at Resident 29's bedside. These failures had the potential for impaired medication integrity or to administer expired medication to residents.

Inspectors wroteBased on observation, interview, and review of facility documents, the facility failed to ensure food service safety when multiple food items with no open date were found in the refrigerators. This failure placed the residents at risk for food borne illnesses.

Inspectors wroteA review of Resident 76's admission Record Report and order summary report indicated Resident 76 was admitted to the facility with diagnose of Acute respiratory failure and was receiving 2 liter oxygen via nasal cannula every shift. During an observation on 11/28/22 at 10:44 a.m., Resident 76 was in bed and was receiving oxygen via nasal cannula. The nasal cannula and sterile water chamber (humidifier) connected to the oxygen tank was not dated or labeled. Resident 76's treatment mask connected to the nebulizer was dated 9/19/22. During an interview on 11/28/22 at 10:48 a.m., with LVN 6, LVN 6 confirmed the oxygen tube and humidifier were not properly dated, LVN 6 stated did not know when nurses changed them and confirmed the date on treatment mask was 9/19/22. LVN 6 stated Resident 76 used the treatment mask for breathing treatment. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 86), had physician's orders for Oxygen (O2) for more than six-months, when O2 was being administered around the clock. This failure resulted in Resident 86 receiving O2 without a physician order.

Inspectors wroteBased on observation, interview, and record review, nursing services did not communicate a doctor's therapy order in a timely manner for Resident 112. This failure resulted in a delay of services needed to maintain Resident 112's physical well-being.