Royal Oaks Manor-Bradbury Oaks

Inspectors wroteBased on interview and record review the facility failed to inform and provide written information regarding advance directives (a legal document explaining a resident's health care wishes if he or she cannot speak for themselves) for two of five sampled residents (Residents 21 and 22). This failure resulted in Residents 21 and 22 being uninformed of their health care rights and had the potential to result in conflict regarding Residents' 21 and 22's health care decision choices.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure, three of three sampled residents (Residents 29, 5 and 46), were provided with appropriate activities of daily living (ADLs, basic self-care tasks like bathing, dressing, eating, using the toilet, and moving around). These deficient practices had the potential to result in physical declines due to the lack of assistance with ADLs for Residents 29, 5 and 46. Cross Reference F550Findings: A. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Destroy discontinued controlled medications (DCM - prescription drugs that have a potential for dependence and have been discontinued) deposited into the MedSafe (MS, refers to a specialized medication disposal receptacle used to manage unused, expired, or unwanted medications, designed to prevent misuse of medications) were still whole, identifiable, retrievable, and left with original packaging (blister packs [individually sealed compartments of medications, one dose per compartment]). 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection (the invasion and growth of germs in the body) prevention and control practices by failing to ensure: a. Masks were readily available upon entrance to the facility. b. Gloves were readily available outside of two of four sampled resident (Resident 3 and Resident 46) rooms, who were on Enhanced Barrier Precautions (EBP - infection control measures, primarily for nursing homes, using gowns and gloves during direct, high-contact care for residents with multidrug-resistant organisms [MDROs] or at high risk). [...]

Inspectors wroteBased on interview and record review, the facility failed to treat one of one sampled resident (Resident 29) with respect and dignity when Certified Nurse Assistant 2 (CNA 2) failed to assist Resident 29 to the restroom making Resident 29 feel bad, like a fireman dummy, and a child. This deficient practice had the potential to affect Resident 29's psychosocial well-being. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a Preadmission Screening and Resident Review Level 2 screening (PASARR II-a required federal assessment that ensures individuals with a mental disorder or intellectual disability are placed in appropriate facilities) for one of one sampled resident (Resident 2) when the facility did not reply to the recommendations by the California Department of Health Care Services (DHCS-a state agency that oversees the provision of health care and mental health services) for an attempted evaluation of PASARR level 2 as indicated by the facility's Policy and Procedure (P&P) titled, admission Criteria. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents' (Resident 5) eye wash irrigating solution, and a non-legend drug (medication that can be purchased over-the-counter [OTC] without a prescription) was not stored inside Resident 5's room. This deficient practice had the potential to result in non-licensed staff or family using the eye irrigating solution to treat Resident 5 and the potential to compromise Resident 5's physical well-being.

Inspectors wroteBased on interview and record review the facility failed to ensure a medication regimen review (MRR-a thorough evaluation of a resident's medications) was completed for one of five sampled residents (Resident 11) when Resident 11 did not have documented evidence of a completed MRR during the months of November and December 2025. This failure had the potential to result in Resident 11 experiencing adverse consequences (impairment or decline in an individual's mental, physical, functional, or psychosocial status [the emotional and social requirements that individuals must have to feel safe, supported, and capable of functioning well in their environment]) from medications. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the following care and services as ordered by Hospice Agency 1's physician:1. An order for Boost (a nutritional supplement drink with essential nutrients to support the resident's nutritional needs) was missed and not included in Resident 1's nutritional supplement orders.2. An order for diclofenac sodium (a drug used in the treatment and management of acute and chronic pain associated with inflammatory conditions) was missed and not included in Resident 1's drug therapy orders. These deficient practices had the potential to result for further resident weight loss and uncontrolled pain.

Inspectors wroteDuring an interview and record review, the facility failed to ensure call lights were answered immediately for two of three sampled residents (Resident 2 and Resident 3). This deficient practice had the potential to result in residents' unmet needs.

Inspectors wroteB. During a review of Resident 23's AR, the AR indicated, Resident 23 was admitted to the facility on [DATE] with multiple diagnoses including shortness of breath, anxiety disorder (a mental health disorder of persistent and excessive feelings of worry or fear that interferes with daily activities), and fever, unspecified. During a review of Resident 23's H&P, dated 9/11/2024, the H&P indicated, Resident 23 had the capacity to understand and/or sign any form. During a review of Resident 23's MDS, dated [DATE], the MDS indicated, Resident 23's cognition (ability to think and process information) status was moderately impaired. The MDS indicated, Resident 23 did not receive the influenza vaccine in the facility. During a concurrent review of the activities CP with the Activities Staff (AS) on 11/14/2024 at 2:46 PM, the AS stated there was no activities CP developed for Resident 23. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to use appropriate alternatives prior to the use of bedrails for two of two sampled residents (Resident 12 and Resident 23.) This deficient practice had the potential to result in accidents for Resident 12 and Resident 23 due to the use of bedrails.

Inspectors wroteBased on interview and record review, the facility failed to ensure accuracy of medical records for one of one sampled resident (Resident 23) by failing to: A. Ensure Resident 23's Medication Administration Record (MAR, a log initialed and/or signed by the nurse with the date and time each time a medication is administered to a resident) was complete when on 9/21/2024, 9/25/2024, and 9/28/2024, the facility's Controlled Drug Record for Hydrocodone-Acetaminophen (pain medication used to relieve moderate to severe pain, works in the brain to change how your body feels and responds to pain) 5-325 mg (milligram, unit of measurement) indicated Hydrocodone-Acetaminophen 5-325 mg was removed and Resident 23's MAR did not reflect administration of Hydrocodone-Acetaminophen 5-325 mg. B. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain its infection prevention and control program for four of seven sampled residents (Resident 2, 26, 41, and 40) by failing to: A. Ensure enhanced barrier precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs, bacteria that have become resistant to certain antibiotics] in nursing homes) were followed and hand hygiene was performed when entering and exiting Room A. B. Ensure the toilet seat was clean in the shared restroom of Resident 2 and Resident 26. C. Ensure an open and unlabeled personal toiletry was not stored inside the shared restroom of Residents 41 and 40 D. Ensure the clean linen was handled properly in the laundry room. [...]

Inspectors wroteB. During a review of Resident 39's AR, the AR indicated, Resident 39 was originally admitted to the facility on [DATE] with multiple diagnoses including anxiety disorder (a mental health disorder of persistent and excessive feelings of worry or fear that interferes with daily activities), encounter for attention to gastrostomy (a surgical procedure used to insert a tube often referred to as a G-tube through the abdomen and into the stomach for feeding and medications) and need for assistance with personal care. During a review of Resident 39's History and Physical, dated 10/16/2024, the H&P indicated, Resident 39 was in NAD (no acute distress) and was awake, alert, and oriented x 3 (to person, place, and time). During a review of Resident 39's MDS, dated [DATE], the MDS indicated, Resident 39's cognition (ability to think and process information) status was moderately impaired. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure grooming was provided to one of two sampled resident (Resident 18) who had dark brown substance under three fingernails of the left hand. This deficient practice had the potential to affect Resident 18's wellbeing and the potential to contaminate Resident 18's environment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure activities were provided to one of three residents (Resident 23). This deficient practice had the potential to affect Resident 23's emotional and psychosocial wellbeing.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 6) received treatment and care in accordance with the physician's order by failing to ensure Resident 6's edema (swelling caused by too much fluid trapped in the body's tissues) was cared for adequately. This deficient practice had the potential to result in Resident 6's edema not improving and had the potential to cause pain and further complications to Resident 6.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure floor mats were in place for one of one sampled resident (Resident 8), who was identified as high risk for falls and as indicated in Resident 8's physician's order, Plan of Care (CP) for at risk for falls, and the facility's policy and procedure (P&P) titled Falls and Fall Risk, Managing. This deficient practice had the potential to result in falls and serious injuries leading to fractures (break in the bone) and bleeding to Resident 8.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow Pharmacist's recommendation to perform a gradual dose reduction (GDR, the stepwise tapering [to reduce dose over time] of a dose to determine if symptoms, conditions, or risks can be managed by use of a lower dose or determination of whether the dose or medication can be discontinued) for Seroquel, an antipsychotic medication (main class of drugs used to treat people that have mental disorders like schizophrenia [mental disorder characterized by loss of contact with the environment]), for one of one sampled resident (Resident 12). This deficient practice had the potential to result in unnecessary use of Seroquel and could potentially lead lethargy and adverse side effects (unwanted, undesired effect of a medication) to Resident 12.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents' (Resident 20) medication, Potassium Chloride (a mineral supplement used to treat or prevent low amounts of potassium in the blood to maintain the health of your kidneys, heart, muscles, and nervous system) ER (Extended Release, designed to release the medication at delayed or slower rates) was administered correctly as indicated in the facility's policy and procedure (P&P) titled, Administering Medications. This failure had the potential for Resident 20 to develop gastric (of the stomach) upset and irritation and possibly lead to further harm and discomfort to Resident 20.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the drugs and biologicals used in the facility were stored properly in one of two sampled medication carts (Med Cart 2). This failure had the potential to impact the effectiveness of the medications located in Med Cart 2 and decrease the efficacy (the ability to produce a desired or intended result) of the drugs. The failure had the potential to compromise the health and safety of Resident 33 and the residents who received medication from Med Cart 2 due to administration of the drugs.

Inspectors wroteBased on interview and record review, the facility failed to ensure administration of the Influenza ([flu] a common, sometimes deadly infection of the nose, throat and lungs) vaccine (are injections [shots], liquids, pills, or nasal sprays you receive to protect you against harmful diseases, before you come into contact with them) for one of five sampled residents (Resident 23), who was eligible and consented to receive the flu vaccine. This deficient practice placed Resident 23 at greater risk for acquiring, transmitting, or experiencing complications from the flu and had the potential to result in a physical decline to Resident 23.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pain management to one of one sampled resident (Resident 1) who was experiencing pain, in accordance with Resident 1's goals for care and preferences. This deficient practice had the potential to result in Resident 1 to continue to experience pain and affect the resident's sense of comfort and wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services to prevent a fall for one of three sampled residents (Resident 1) by failing to: 1. Ensure Certified Nursing Assistant 1 (CNA 1) provided two-person physical assistance (help from two persons) to transfer (moving a resident from one place to another) Resident 1 from the toilet to the wheelchair when CNA 1 used the Sara lift (mechanical lift, a device used by staff to transfer residents from one location to another e.g., a bed to a chair). 2. Ensure CNA 1 followed the facility's Policy and Procedures (P&P) titled, Lifting Machine, Using a Mechanical, and Fall & Fall Risk, Managing. As a result, on 4/23/2024, at 3 p.m., Resident 1 fell forward from the Sara lift. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) who had a diagnosis of dementia (loss of memory and other mental abilities severe enough to interfere with daily life), was assessed at high risk for falls, and elopement (a resident who's incapable of protecting himself/herself adequately and who departed the health care facility unsupervised and undetected) received care and services to prevent a fall by failing to: 1. Implement Resident 1's Care Plan (CP, a form where one can summarize a person's health conditions, specific care need, and current treatments) interventions related to repetitive wandering (moving from place to place without a fixed plan) behavior and attempts to leave the facility unattended. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement interventions to prevent and control the spread of COVID-19 (Coronavirus disease, a severe respiratory illness caused by virus and spread from person to person) in accordance with the facility ' s COVID-19 Mitigation Plan (facility ' s plan to minimize the effect of COVID-19 and to reduce loss of life) guidelines by failing to ensure: Licensed Vocational Nurse 1 (LVN 1) wore a fitted (fit test - a test to determine how effectively a mask or respirator will protect the wearer) N95 mask or respirator (a respiratory protective device designed to achieve a very close facial fit and efficient filtration of airborne particles) in the facility during a COVID-19 outbreak. This deficient practice had the potential to result in the spread of COVID-19 to other residents and staff in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 1 and Resident 20) were treated with dignity by failing to provide privacy during medication administration. This deficient practice resulted in exposure to Resident 1 and Resident 20's abdomens (belly) and could have resulted in a psychosocial decline to Resident 1 and Resident 20 due to feelings of humiliation, embarrassment, and being ashamed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 194 and Resident 195) had a baseline (initial) care plan (CP provides direction on the type of nursing care an individual needs that include goals of treatment, specific nursing interventions [actions, treatments, procedures, or activities designed to meet an objective] and an evaluation plan]) developed and implemented within forty-eight hours of admission to the facility. This failure had the potential to result in lack of communication among staff members, specific care needs and current treatments not implemented, and a decline in Residents 194 and 195's physical well-being

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and/or implement an individualized person-centered care plan for three of three sampled residents (Residents 11, 94 and145). a. For Resident 11, there was no care plan developed to address Resident 11's retention of urine. b. For Resident 145, there was no care plan developed to address Resident 145's aggressive behavior. c. For Resident 94, there was no care plan developed to address Resident 94's constipation. These deficiencies had the potential to result in inconsistent implementation of care and services and/or missed opportunities in identifying risk for Residents 11, 94 and 145.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 27) received treatment and care in accordance with facility's Policies and Procedures (P&P) by failing to notify Resident's 27 physician regarding Resident 27's refusal to take a prescribed medication, Mucinex (helps loosen congestion [an abnormal or excessive accumulation of a body fluid] in your chest and throat, making it easier to cough out through your mouth) on October and November 2023. This deficient practice had the potential to result in the development of chest congestion and difficulty breathing for Resident 27.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent falls and ensure a safe environment for one of one sampled resident (Resident 19). Resident 19 fell on 7/2/23, 8/23/23, and on 10/29/23 and the facility failed to revise Resident 19's Fall Care Plan (CP) after every fall. This failure resulted in multiple falls and had the potential to result in major injuries, hospitalization, and a decline in Resident 19's physical well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the residents were free from any significant medication error for one out of 16 residents (Resident 27). This failure resulted in a decreased medication efficacy (ability to produce a desired or intended result) for Resident 27 and Resident 27 may have experienced health complications related to incorrect medication administration which could have negatively impacted his health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sanitary conditions were maintained when, a. the liquid, in one of three red buckets (Bucket 1), used to sanitize contact surface areas in the kitchen was maintained at the correct concentration of 200-400 parts per million (ppm, unit of measurement). b. foods in one of one nourishment room refrigerator (Refrigerator 1) were not covered or labeled. These failures had the potential to result in cross contamination (process by which bacteria can be transferred from one area to another) and the spread of food borne illnesses (food poisoning) amongst the residents residing at the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of two sampled residents (Residents 194 and 196) were provided a sanitary environment to help prevent the development and transmission of infection (the establishment of an infective agent in or on a suitable host, producing clinical signs and symptoms e.g., fever, redness, heat, purulent exudates, etc.) by failing to properly discard and store the resident's care items. For Residents 194 and 196, the residents shared the same restroom but nursing staff failed to discard the white top hat specimen collector after one use and failed to rinse and store the used graduated cylinder in the drawer located at the bottom of Resident 164's closet. This failure had the potential to result in cross contamination and the transfer of an infectious agent which could compromise Resident 194 and Resident 196's health.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure an assessment was conducted to self-administer medications for one of one sampled resident (Resident 27). This failure had the potential to result in a decline for Resident 27's physical well-being.

Inspectors wroteBased on interview and record review, the facility failed to provide copies of medical records within two working days in accordance with the facility's Policy and Procedure (P&P) on Medical Records Requests for one of one sampled resident (Resident 3). This deficient practice had the potential to violate resident's right to have access to own medical records in a timely manner.

Inspectors wroteBased on interview and record review, the facility failed to accurately code fall incidents on two Minimum Data Sets (MDS, an assessment and screening tool) for one of one sampled resident (Resident 19). This failure resulted in an inaccurate assessment of Resident 94 and had the potential to affect Resident 19's physical well-being.

Inspectors wroteBased on interview and record review, the facility failed to revise a comprehensive Care Plan (CP) for one of one sampled resident (Resident 19) following fall incidents on 7/2/23, 8/23/23, and on 10/29/23. This failure had the potential to result in major injury and a physical decline to Resident 19.

Inspectors wroteBased on interview and record review, the facility failed to ensure irregularities identified from the monthly drug regimen review reported by the facility's pharmacist on the use of Remeron (a medication to treat depression [feelings of sadness and/or a loss]) were acted upon for one of five sampled residents (Resident 22) in accordance with the facility's Policy and Procedure (P&P) on Pharmacist Medication Regimen Review and Reporting. This deficient practice had the potential to result in unnecessary medication administration and potentially cause harm to Resident 22.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 22) who was on Seroquel (medication used to treat mental health condition), received a Gradual Dose Reduction (GDR- tapering a dose of medication) as indicated in the facility's Pharmacist's Recommendation and facility's Policy and Procedure (P&P) on Medication Management. This deficient practice had the potential for Resident 22 to receive unnecessary psychotropic medication (any medicine that affects behavior, mood, or thoughts) and be at risk for harm/injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the facility's medication error rate was not at five percents (%) or greater. The facility had two errors in 28 opportunities during medication pass which yielded a 7.14% medication error rate for one of three sampled residents (Resident 1). For Resident 1, two medications were crushed, combined, and administered at once via the gastrostomy feeding tube (G-tube or GT, a tube inserted through the belly that brings nutrition directly to the stomach). This failure had the potential to cause chemical incompatibility and incomplete dosage for Resident 1's medications and could cause GT complications such clogging up the tube.