San Marino Healthcare Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the resident's right to be free from physical abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) for one of two sampled residents (Resident 1) when Certified Nursing Assistant 2 (CNA 2) grabbed and pulled Resident 1's hair on 6/10/2026 in accordance with the facility's policy and procedure (P&P). This deficient practice had the potential to affect Resident 1's psychosocial (combined influence of psychological factors and the surrounding social environment on physical, emotional, and/or mental wellness) well-being.

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate (being completely free from mistakes, errors, or defects) resident medical records for two (2) of 2 sampled residents (Resident 1 and 2) by failing to ensure:Resident 1's Fall risk evaluation (a simple, straightforward check-up used to determine how likely you are to fall and get hurt) dated 3/29/2026 and 5/24/2026 were accurate. Resident 2's Fall risk evaluation dated 4/13/2026 and 4/21/2026 were accurate. This deficient practice had the potential for Resident 1 and 2 not to identify and address fall risk factors and interventions to minimize and prevent future falls.

Inspectors wroteBased on interview and record review, the facility failed to monitor every, one (1) to two (2) hours the whereabouts of 1 of 2 sampled residents (Resident 2) who wander (to move around different places usually without having a particular purpose or direction) in accordance with the facility's policy and procedure. This deficient practice had the potential to result in Resident 2 wandering into another resident's room, which placed the resident at risk for another injury and potential serious harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote dignity and respect for three (3) of three residents (Resident 8, 7, and 39) reviewed under dignity care area when:Certified Nursing Assistant 1 (CNA 1) used labels to address Resident 8 on 1/6/2026. CNA 1 used labels to address Resident 7 and was standing over while assisting the resident during meals on 1/6/2026. Facility staff used labels when addressing Resident 39 on 1/6/2026, 1/7/2026 and 1/8/2026. These deficient practices had the potential to affect Resident 8,7, and 39's sense of self-worth and self-esteem which could negatively affect the residents' emotional and mental well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy to maintain a safe, clean, comfortable, and homelike environment for three (3) of five (5) sampled residents (Residents 2, 4, and 44) under environment task, when the facility failed to ensure:Resident 2's room was free of trash on the floor, and the wall did not have splattered brownish colored stains. Resident 4's wheelchair was in good condition, with no peeling armrests. Resident 44's wheelchair was in good condition, with no peeling armrests. These deficient practices had the potential to negatively affect Residents 2, 4, and 44 well-being and quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide grooming services for two (2) of three (3) sampled residents (Resident 9 and 22) under activities of daily living (ADLs- are activities related to personal care that include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating) care area, in accordance with the facility's policy. This deficient practice resulted in Resident 9 and 22 having long and jagged (having rough, sharp points protruding) fingernails, potentially leading to skin injury, infection, and scarring (mark left on the skin after a wound or injury has healed).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe environment for three (3) of six (6) sampled residents (Residents 6, 44, and 45) reviewed under accidents care area, as indicated on the facility policy by failing to: Ensure electrical cords were properly organized and were not wrapped around the metal bed frame of Resident 44. Implement interventions to address Resident 6's wandering behavior, who entered another resident's room. Implement interventions to address Resident 28's wandering behavior, who entered another resident's room. This deficient practice placed Resident 44, 6, and 28, as well as other residents in the facility, at risk for serious injury and/or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor the use of anticoagulant therapy ( AC,a medical treatment using drugs, called blood thinners, to prevent or treat dangerous blood clots [thrombi] by slowing down the blood's clotting process, stopping existing clots from growing, and preventing new ones from forming) for two (2) of 2 sampled residents (Residents 2, and 39) under AC care area, as indicated on the facility's policy when facility failed to:1. Monitor Resident 2 for signs and symptoms of bleeding while receiving Heparin injection (is an anticoagulant used to decrease the clotting ability of the blood and help prevent harmful clots from forming in blood vessels) on 11/16/2025 to 11/18/2025.2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety in accordance with the facility's policy and procedure (P&P) titled Glove Use Policy by failing to:Ensure dietary staff (Cook 1, Kitchen Staff 1 and 2) performed hand hygiene (is the act of cleaning the hands with soap or handwash and water to remove viruses/bacteria/microorganisms, dirt, grease, or other harmful and unwanted substances stuck to the hands). Change gloves during cooking and tray line assembly. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the antibiotic (a drug that kills or stops the growth of harmful bacteria) stewardship (the effort to measure and improve how antibiotics are prescribed by and used by residents) was completed for two (2) of 2 residents (Residents 20 and 2) while receiving antibiotic treatment in the facility. This deficient practice had the potential for Residents 20 and 2 to develop antibiotic resistance (when bacteria, viruses, fungi, and parasites no longer respond to antimicrobial medicine and become ineffective making infections difficult or impossible to treat increasing the risk of disease spread, severe illness, disability, and death) and suffer adverse side effects (an undesired harmful effect resulting from a medication or other intervention) from unnecessary or inappropriate antibiotic use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe, clean, comfortable, and home like environment for two (2) of five sampled residents (Resident 8 and 20) under environment care area, when the facility failed to ensure air vents ( openings in buildings for air passage, essential for ventilation, air circulation, and maintaining indoor air quality) inside the resident's rooms were free from dust particles. This deficient practice had the potential for the residents to feel discomfort and suffer from respiratory problems which could negatively affect the residents' well-being and quality of life.

Inspectors wroteBased on interview and record review, the facility failed to notify the medical doctor (MD) of changes with the residents' condition for two (2) of 22 sampled residents (Residents 57 and 20) as indicated in the facility's policy and procedures (P&P):Resident 57's refusal of medications and meals from 11/5/2025 to 11/10/2025. Resident 20's new complaint of itching on bilateral hands and feet on 1/6/2026. These failures resulted in delayed treatments and interventions for Residents 20 and 57 with the potential for inadequate care, services and a preventable decline in Resident 20's and 57's mental, physical and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (1) of three (3) sampled residents (Resident 39) under activities of daily living care area was provided a communication board (pre-printed board that has pictures, numbers, and user defined images that allows a resident to point or indicate on the board what he/she wants communicated) with the language that the resident was able to understand and speak (primary language) in accordance with the facility policy and procedure. This deficient practice prevented Resident 39 from communicating with the staff and had the potential to delay receiving appropriate care/treatment that the resident needed. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide appropriate discharge planning (the process of preparing a resident to safely transition from a hospital or care facility to the next level of care) as indicated in the Director of Social Services job duties and the resident's care plan (a document that outlines the facility's plan to provide personalized care to a resident based on the resident's needs) for one (1) of 1 sampled resident (Resident 45) from the discharge care area. This failure resulted in a delay in discharge planning for Resident 45, with the potential for a delayed discharge from the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that an alternative meal was offered and provided to one (1) of 1 sampled resident (Resident 45) from the choices care area, after his lunch meal was refused, as indicated in facility policy. This failure resulted in Resident 45 having preventable hunger with the potential risks for decreased feelings of well-being and/or malnourished (lack of proper nutrition, caused by not having enough to eat, not eating enough of the right things, or being unable to use the food that one does eat).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) for two of five sampled residents (Residents 21 and 2) from the infection control care area were followed in accordance with the facility's policy and procedure when: 1. a. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect one of two residents (Resident 1) from physical abuse (intentional bodily injury such as pinching, slapping and hitting) when Resident 2 hit, slapped, and scratched Resident 1 on 7/1/2025 in accordance with the facility's policy and procedure (P&P) titled, Abuse Prevention Program,. This deficient practice resulted in, abrasions (wound where skin rubs off due to friction) on Resident 1's left face, left upper cheek and left side of the forehead; abrasion on the middle left outer forearm; bruising on the distal (location on the body farther away from the center of the body) left outer wrist; [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent a sexual abuse (when someone touches another person in a sexual manner, unwanted touching of a sexual nature, or makes that person take part in sexual activity with them without consent) for one of two sampled residents (Resident 1) when Resident 2 touched Resident 1's buttocks and exposed Resident 2's private parts in front of Resident 1 on 4/12/2025 at around 6:50 AM. This deficient practice violated Resident 1's rights to befree from abuse and has the potential to have negative psychosocial (the combined influence of thoughts, feelings, behaviors, relationships and environment on a person's wellbeing and how they function) outcomes to the resident.

Inspectors wroteBased on observations, interview and record review, the facility failed to report a sexual abuse (when someone touches another person in a sexual manner, unwanted touching of a sexual nature, or makes that person take part in sexual activity with them without consent)for one of two sampled residents (Resident 1) to the State Survey Agency (SSA), the Ombudsman (advocates for residents of nursing homes, board and care homes and assisted living facilities), and local law enforcement (Local PD) within two (2) hours from when Certified Nurse Assistant (CNA) 1 witnessed Reisdent 2 inappropriately touched Resident 1 buttocks and when Resident 2 exposed his private area in front of Resident 1 and CNA 1 on 4/12/2025 at 6:50 AM. This deficient practice had the potential to place Resident 1 and other residents for further abuse.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one (1) of two (2) sampled residents (Resident 1) privacy was protected while Resident 1 was using the restroom/bathroom on 2/28/2025 in accordance with the facility's policy titled, Resident Rights. This deficient practice violated Resident 1's rights to privacy and has the potential to have negative psychosocial (the combined influence of thoughts, feelings, behaviors, relationships and environment on a person's wellbeing and how they function) outcomes to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (1) of two (2) sampled residents (Resident 1) was free from an unnecessary psychotropic drug (any medication capable of affecting the mind, emotions, and behavior) in accordance with the facility policy and procedure (P&P) titled Psychotropic Medication Use, by failing to ensure: A. Resident 1 have indication for a specific target behavior such as sudden striking or hitting another resident in the physician's order dated 2/17/2025 for the use of Risperdal (medication to treat certain mental/mood disorders). B. Resident 1 have an order to monitor and / or record occurrence of target behavior such as sudden striking for the use of Risperdal. C. Resident 1 have an order to monitor and document/report any adverse (harmful) reactions to Risperdal. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), wore the [NAME] brace (a brace used to stabilize and treat broken bones in the upper arm) as ordered by the physician and indicated in Resident 1 ' s care plan. This failure placed Resident 1 at risk for delayed healing and/or worsening of the right humerus fracture (a break in the upper arm bone on the right side of the body) and a decline in right arm range of motion (ROM, the full movement potential of a joint, usually its range of flexion and extension).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident with Language barrier was provided a communication board (pre-printed board that has pictures, numbers, and user defined images that allows a resident to point or indicate on the board what he/she wants communicated) with the language that the resident was able to understand for two of three sample residents (Resident 24 and 28) in accordance with the facility policy and procedure. This deficient practice prevented the residents from communicating with the staff and had a potential to delay receiving appropriate care/treatment the residents needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the storage, preparation and distribution of food was done under sanitary conditions (clean and healthy) in accordance with the facility policy by failing to ensure : 1. Food items inside kitchen produce refrigerator and dry storage (a method of conserving temperature and humidity without the need for refrigeration) were labeled with a received date and/ or expiration date, and expired food items were discarded and not mixed with other non-expired foods. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that maintained or enhanced a resident's dignity and respect for two (2) of 15 sampled residents (Resident 37 and 42) by failing to ensure facility staff did not stand over and above resident's eye level while assisting the resident during meal. This deficient practice had the potential to affect Resident 37 and 42's self-esteem and self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility licensed staff failed to obtain an informed consent (a process in which a resident and his/her medical provider communicate about medical procedure or treatment, including its possible risks and benefits, and the resident agrees to it) from the resident's responsible party before administering Quetiapine Fumarate (an antipsychotic medication, a drug used to treat serious mental health conditions), for one (1) of 15 sampled residents (Resident 19) in accordance with the facility policy. This deficient practice violated the resident's right to be fully informed and consent to receive psychoactive medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodation to meet the resident's needs for three (3) of 15 sampled residents (Residents 37, 45, and 208) in accordance with the facility policy when: 1. Resident 37 with limited range of motion (ROM, extent of movement of a joint) of bilateral hands was not provided with an appropriate call device (a device used by residents to call staff). 2. and 3. Resident 45 and 208's call lights was observed not within arm's reach. These failures had the potential to result in a delay in or in an inability for Residents 37, 45, and 208 to obtain necessary care and services especially during an emergency, which could result in injury and harm.

Inspectors wroteBased on interview and record review, the facility failed to follow its Advance Directive (a written instruction, such as a living will or durable power of attorney for health care, recognized under State law relating to the provision of health care when the resident is incapacitated [clinical state in which a resident is unable to participate in a meaningful way in medical decisions]) policy for one (1) of four (4) sampled residents (Resident 208) by failing to inform and provide the resident a written information on the option to formulate an advance directive. This deficient practice had the potential for Residents 208 to not be informed of his right to formulate an advance directive and for the staff not to carry out the resident's wishes regarding health care decisions during an emergency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, and homelike environment for two (2) of six (6) sampled residents (Residents 45 and 208) as indicated on the facility's policy when: 1. Residents 45's overhead lights in the resident's room did not have a bulb. 2. Resident 208's wheelchair had multiple holes and ripped edges on its seat. Resident 208's overhead lights in Residnet 28's room did not have a cord to turn the lights on and off. These deficient practices have the potential to negatively affect Resident 45 and 208's safety and quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living (ADL) receives services to maintain good hygiene/ grooming for one (1) of two (2) sampled residents (Resident 8) by failing to clip Resident 8's long and dirty fingernails. This deficient practice resulted in Resident 8 not receiving fingernail care and had the potential to negatively impact Resident 8's self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility did not maintain an accident-free environment for one of 15 sampled resident (Resident 8) by failing to ensure there were no open A&D ointment (medication used as a moisturizer to treat or prevent dry, rough, scaly, itchy skin and minor skin irritations ,such as diaper rash, skin burns from radiation therapy) at Resident 8's bed side table. This failure had the potential to cause injury and harm in the event the medication was ingested by residemts here in La Union.

Inspectors wroteBased on interview and record review, the facility failed to maintain facility staff documentation of the current Coronavirus disease 2019 (COVID-19, a disease caused by a virus named SARS-CoV-2 which stands for severe acute respiratory syndrome coronavirus 2) vaccination status for four (4) of 73 facility staff as indicated in the facility's policy. This deficient practice had the potential to not accurately reflect which facility staff were at risk from contracting the COVID-19 disease which could potentially spread to other staff and the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Daily Staffing Report (Nurse Staffing Information) posted was accurate and complete in accordance with the facility's policy and procedure by failing to: 1. Ensure the Daily Staffing Report on 11/11/2024 was posted. 2. Reflect the correct total number and actual hours of certified nursing assistants directly responsible for resident care for 11/8/2024, 11/11/2024, 11/12/2024, and 11/13/2024. These deficient practices had the potential for residents and visitors not being informed of the census and staffing for the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure the fall care plan (a document that outlines the facility ' s plan to provide personalized care to a resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs) for one (1) of three (3) sampled residents (Resident 1), included resident-centered interventions (programs or activities that are designed to address the specific needs of the resident to ensure their well-being) per facility policy. This deficient practice resulted in Resident 1 not having resident-centered fall prevention interventions, with the risk for potential falls with injury.

Inspectors wroteCross reference with F610 Based on interview and record review the facility failed to report to the state agency (CDPH, California Department of Public Health), the state ombudsman (advocates for residents of nursing homes, board and care homes and assisted living facilities), and local law enforcement of an allegation of physical abuse (intentional bodily injury) for one of two sampled residents (Resident 1). This failure had the potential to place Resident 1 and other residents at risk for physical abuse, which could result to harm/injury.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy for abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) for one (1) of two (2) sampled residents (Resident 1) by failing to: 1. Conduct a thorough investigation of an allegation of physical abuse (intentional bodily injury) reported by Resident 1's family representative (FR) on 8/22/24. 2. Provide a written report to the State Survey Agency of the findings of the physical abuse allegation investigation within five (5) working days of the incident. This failure had the potential to place Resident 1 and other residents at risk for physical abuse, which could result to harm/injury.

Inspectors wroteBased on observation, interview, and record review the facility failed to supervise and ensure the safety of one (1) of two (2) sampled residents (Resident 1) in accordance with the facility's policy and procedure when Resident 1 left the facility through his window. This failure resulted in Resident 1 eloping (leaving the facility without the staff's knowledge and/or supervision) on 7/23/24 and is not found as of 7/31/24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe environment to prevent accidents for one of two sampled residents (Resident 1) by: 1. Facility failed to provide supervision to Resident 1 who was identified by the facility as a low risk for elopement (to leave a secured institution without notice or permission) when the facility exit doors were not supervised and the gate was left open on 4/26/2024. This deficient practice resulted to Resident 1 eloped on 4/26/2024 at 1:48 PM which can result to serious injury, harm, and/ or death. 2. Facility failed to ensure one of four staff (Certified Nursing Assistant 3 - CNA 3) had the competency necessary to care for residents when fire alarm is on. This deficient practice placed Resident 1 and other residents in the facility at risk for elopement. 3.

Inspectors wroteAmended: Based on observation, interview, and record review, the facility failed to ensure the gastrostomy tube (GT, small plastic tube inserted through the skin into the stomach to bring nutrition directly to stomach) feeding tube for two (2) of three (3) sampled residents (Residents 36 and 24) was capped with a protective covering when it was disconnected from the resident, as indicated in the facility policy. This deficient practice had the potential to place Residents 36 and 24 at risk for infection control, which could result to resident harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to use the correct measuring scooper (a food serving utensil used to measure even portions) for the servings of pureed fruit given to nine (9) of 9 sampled residents (Residents 1, 12, 13, 20, 21, 25, 29, 36 and 42) in accordance with the facility's Measurement Chart. This failure had the potential to result in Residents 1, 12, 13, 20, 21, 25, 29, 36 and 42, not meeting their daily nutritional dietary needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper sanitation and food handling practices were followed, in accordance with the facility's policies and procedures for 55 of 55 residents in the facility by ensuring: 1. The can opener and blender base was kept clean. The can opener was observed with sticky gunk (material that is dirty, sticky, or greasy) and food residue. The blender base was observed with dirt build ups and blender metal part was falling off. 2. The kitchen knives were maintained in good repair and kept clean. The kitchen knives were observed with the handles worn out and with blackish gray discoloration. 3. The parsley flakes and italian seasoning containers were properly sealed, and flour container was covered. 4. The package of Muse Enhanced Tea was properly labeled. 5. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a resident centered care plan (document that outlines the facility's plan to provide personalized care to a resident based on the resident's needs) for one of 14 sampled residents (Resident 8), when a sore (an injury that involves a break in the skin) developed on Resident 8's bottom lip. This failure had the potential for Resident 8 not to receive individualized care plan interventions, which could result in a lack or delay of treatment and worsening of Resident 8's bottom lip sore. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the wheelchair, occupied by a resident, was in the locked position for one of three residents (Resident 21) as indicated on the facility policy. This failure has the potential to result in Resident 21 falling and being injured.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide oxygen therapy (treatment that provides supplemental, or extra oxygen) and necessary respiratory care services for one (1) of 1 sampled resident (Resident 27) in accordance with the facility's policy and care plan when Resident 27 did not have a physician's order to receive oxygen at five (5) liters per minute (lpm, unit of measurement) via nasal cannula (device used to deliver supplemental oxygen placed directly on a resident's nostrils). This deficient practice had the potential to result in respiratory distress and/or other complications for Resident 27.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain safe and functional sink in one (1) of three (3) residents shower rooms (Shower Room A) when Shower Room A's sink was observed to have sharp wood edges and metal screws sticking out. This deficient practice had the potential for residents to be placed at risk for injury.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy to develop a plan of care for one of six sampled residents (Resident 1) to address resident's behavior of wandering (traveling aimlessly from place to place) into other residents' room. This deficient practice had the potential to result in Resident 1 being abused by another resident or having another resident- to- resident altercations.