Santa Monica Rehabilitation Center

Inspectors wroteBased on interview and record review, the facility failed to ensure that the resident rights to be informed regarding informed consent (provider explaining a treatment's risks, benefits, and alternatives so a patient can freely agree to or refuse care) for psychotropic (any substance or medication that changes how the brain works, affecting a person's mood, thoughts, feelings, behavior, or perception) medication was adhered to for one of one sampled residents (Resident 1) according to according to the facility's policy and procedures (P&P) titled Informed Consent for Psychotropic Drugs -Pharmacy services dated 1/29/2026. This deficient practice resulted in the violation of Resident 1's rights to be informed and make decisions about psychotropic medication.

Inspectors wroteBased on observation and interview, the facility failed to ensure that the resident was cared for in a manner that promoted and enhanced the wellbeing, feeling of self-worth and self-esteem for one of one sampled resident (Resident 2) according to the facility's policy and procedures (P&P) tiled Dignity, revised 1/29/2026. This deficient practice resulted in Resident 2 not being cared for in a manner that promoted and enhanced her wellbeing and feeling of self-worth.

Inspectors wroteBased on observation, and interview, the facility failed to ensure that guidelines for the use if a pump for enteral feeding were adhered to according to the facility's policy and procedure (P&P) titled Enteral Tube Feeding Via Continuous Pump, dated 1/21/2026 for one of one sampled resident (Resident 1) when, tube enteral feeding formular was hang without a date or rate, enteral feed free water was hang without a label and tube feeding formula was not labeled. This deficient practice had the potential to cause infection and/or possible hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to ensure nursing staff met the specific competency requirement of their respective licensure and certification for one of two sampled staff (Certified Nursing assistant [CNA] 1) according to the facility's policy and procedures (P&P) tiled Competency of Nursing Staff, revised 1/29/2026. This deficient practice had the potential to negatively impact on the safety and wellbeing of the residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure that the facility was free of pests (cockroaches). This deficient practice had the potential to place all 144 residents residing in the facility at risk of vector-borne diseases (Illness that results from infections transmitted to humans by insects, such as cockroaches) and infectious diseases transmitted by pests (cockroaches). During a review of Resident 2's admission record indicated that Resident 2 was admitted on [DATE] with diagnoses including cerebral infarction (when a blood vessel to the brain is blocked stopping blood and oxygen from reaching the brain resulting in brain cell death), generalized anxiety disorder (a mental health condition marked by excessive worry, constant tension, and feeling restless), and hypertension (HTN-high blood pressure). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to document the resident's assessment accurately in the medical record for one of five sampled residents (Resident 1). This failure resulted in inaccurate/ incomplete documentation of Resident 1's special treatments, procedures, and programs in the Minimum Data Set (MDS - a resident assessment tool), and had the potential to affect the services and treatments rendered. During a review of Resident 1's admission Record, dated 7/17/26 indicated, the resident was admitted to the facility on [DATE] with diagnoses including; [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure comprehensive care plans were updated and revised for one of five sampled residents (Resident 1) after hospitalization. This failure had the potential to affect resident care, services and treatments. During a review of Resident 1's admission Record, dated 7/17/26 indicated, the resident was admitted to the facility on [DATE] with diagnoses including; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a discharge plan in the comprehensive care plan for three of three sampled residents (Residents 1,2, and 3). This deficient practice resulted in unsafe discharge, with a potential of worsened health outcomes, severe medical errors, and hospitalization. a. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was readmitted on [DATE] (original admission date 6/1/2021). With diagnoses including but not limited to type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), Cellulitis (bacterial skin infection) of right lower limb, and dysphagia (difficulty swallowing). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a notification of transfer to one of three sampled residents (Resident 1). This deficient practice resulted in Resident 1 experiencing emotional distress and uncertainty. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was readmitted on [DATE] (original admission date 6/1/2021). With diagnoses including but not limited to type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), Cellulitis (bacterial skin infection) of right lower limb, and dysphagia (difficulty swallowing). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Certified Nursing Assistant (CNA) 1 was in-serviced and given clear instruction on the protocols of how to mitigate physical and environmental hazards including falls for one of four sampled residents (Resident 1) according to Resident 1's care plan (CP-a personalized, written roadmap that outlines a patient's specific health issues, medical goals, and the exact treatments or services needed to achieve them). On 6/12/2026, CNA 1 was assigned to monitor and supervise Resident 1 who was using a Merry [NAME] (MW- a specialized/mobility device that combines a fully enclosing, 4-wheeled walker with an attached trailing chair which enables independent ambulation for Residents with poor balance) for ambulation, had a history of falls, and had a behavior of suddenly getting up and walking very fast. [...]

Inspectors wroteBased on observations, interview, and record review, the facility failed to follow its' policy and procedure (P&P) titled, Bioethics Committee- Residents Rights and Dignity, revised 1/29/2026, by failing to honor the rights of one of the three sampled residents (Resident 5) who had fluctuating capacity to make decisions. This deficient practice resulted in Resident 5 being unable to make decisions regarding her care. [...]

Inspectors wroteBased on observations, interview, and record review, the facility failed to follow its' own policy and procedures (P&P) titled, Resident Rights, revised 1/29/2026 for one of the three sampled residents (Resident 1) by failing to prevent the loss of her compression hose (compression stockings - specialized, snug-fitting elastic garments worn on the legs. They apply gentle, graduated pressure that is tightest at the ankle and decreases as it moves up the leg. This pressure helps improve blood flow and prevents swelling). This deficient practice resulted in Resident 1 being unable to wear her compression hose when she wanted to. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of two Certified Nursing Aides (CNA 1 and CNA 2) were competent (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully), spoke English according to the facility's job description titled Certified Nurses Assistant and the facility's policy and procedures (P&P) titled Job Descriptions and Performance Evaluation with a revision date of 2/2026, and are able to identify and report abuse. This failure resulted in CNA 1 and CNA 2 inability to name types of abuse with the potential for the residents to suffer abuse resulting in psychological trauma, pain, and physical injuries.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedures (P&P) titled, Change in a Resident's Condition or Status, reviewed 1/29/2026 by failing to accurately assess one of the four sampled residents (Resident 1) for risk of elopement after the resident by attempted to elope (when a resident leaves the facility grounds or a designated safe area without the staff knowing and/or without the supervision the resident needs) from the facility on 3/30/2026. This deficient practice resulted in Resident 1 successfully eloping from the facility on 5/27/2026 and 6/2/2026.

Inspectors wroteBased on interview, and record review, the facility failed to staff accurately assess one out of three sampled residents (Resident 1) who was experiencing chest pain and had abnormal laboratory results by failing to ensure that:Licensed nursed comprehensively assessed Resident 1 after the resident complained of chest pain on 6/2/2026. Licensed nurses re-assessed Resident 1 after administering nitroglycerine [fast-acting prescription medication used to prevent and rapidly relieve chest pain] 0.4 milligrams [mg- units of measurement] for chest pain on 6/2/2026 at 8:30 pm. [...]

Inspectors wroteBased on interviews and record review, the facility failed to have a system in place to ensure the safety of one of the three sampled residents (Resident 1) by failing to: Licensed nursed comprehensively assessed Resident 1 after the resident complained of chest pain on 6/2/2026. Licensed nurses re-assessed Resident 1 after administering nitroglycerine [fast-acting prescription medication used to prevent and rapidly relieve chest pain] 0.4 milligrams [mg- units of measurement] for chest pain on 6/2/2026 at 8:30 pm. [...]

Inspectors wroteBased on interview, and record review, for two of twelve sampled residents (Residents 1 and 9):For Resident 1:A. The facility failed to provide adequate supervision and implement effective interventions to prevent elopement (when a resident leaves the facility grounds or a designated safe area without the staff knowing and/or without the supervision the resident needs) for one of three sampled residents (Resident 1) who had moderate cognitive impairment by failing to:1. Monitor and supervise the whereabouts of Resident 12. Accurately assess Resident 1's risk for elopement on 3/30/26 when Resident 1 displayed wandering behavior and attempted to elope from the facility.3. Create and implement a Risk for elopement care plan after Resident 1 attempted to elope on 3/30/2026 and eloped on 5/27/2026.4. [...]

Inspectors wroteBased on observation, interview, and record review, for five of five sampled residents (Residents 2, 10, 11, 17 and 47), the facility failed to:Develop/initiate and/or implement a comprehensive and individualized person-centered plan of care with measurable objectives, timeframe, and interventions to meet the residents' needs for Residents 10 11, and Resident 47 in accordance with the facility's policy and procedures (P&P) titled Care Plans, Comprehensive Person-Centered with review date of 1/29/026.1. Resident 2 was on antibiotics (medication used to treat infection/s).2. Resident 10 had a diagnosis of dementia (a progressive state of decline in mental abilities).3. Resident 11 had a diagnosis of post-traumatic stress disorder (PTSD -a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event).4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary respiratory care services for two of two sampled residents (Resident 45 and Resident 48) when the facility failed to:For Resident 45:1. The facility failed to ensure that facility staff administered oxygen to Resident 45 when the oxygen saturation (O2 Sat- a measurement of how much oxygen the blood is carrying as a percentage) level was less than 92 percent (% - unit of measurement) per physician order. This deficient practice resulted in Resident 45 receiving more oxygen than required and can negatively impact the resident's well-being with the potential for hospitalization. For Resident 48:2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 35 out of 132 Soft-and-Bite-Sized (SB6) texture modified meal lunch trays were prepared according to the International Dysphagia Diet Standardization Initiative (IDDSI: standardized framework [0-7 levels] that uses consistent terminology, colors, and testing methods to define texture-modified foods and thickened liquids for people with swallowing difficulties [dysphagia]. Level 6-designed for individuals with mild dysphagia or chewing difficulties. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and distribution practices, by failing to:Ensure kitchen staff practiced sanitary glove use during meal preparation. Prevent the contamination of food contact surfaces from cloths and rags. Ensure the kitchen's can opener blade was kept clean. Ensure the floors under kitchen equipment were not heavily soiled with debris. These deficient practices had the potential to result in harmful bacterial growth that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or toxins) in 132 of 133 residents who received food from the facility kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one out of one sampled resident (Resident 63) was wearing an identification (ID) armband (a resident identification system used to help facility personnel provide medical and nursing care) according to the facility's policy and procedures titled, Resident Identification System, dated 1/9/2026. This failure had the potential to result in physical and psychosocial harm to the resident.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain dignity (providing care that respects a resident's self-esteem, identity, and personal choices) and respect for one of one sampled resident (Resident 80) as per the facility's policy and procedure (P&P) tiled Dignity revised on1/29/2026, when Certified Nursing Assistant (CNA) 2 stood over Resident 80 when feeding the resident. This failure had the potential to violate Resident 80's right to personal dignity, and respect, and could negatively affect Resident 80's psychosocial well-being and have impact on Resident 80's self-esteem (sense of personal worth and value).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call light was within reach for two of two sampled residents (Resident 110 and Resident 122). This failure practice resulted in Resident 122 feeling frustrated and the potential to not meet the needs of the resident and had the potential for Resident 110 to not communicate needs to the staff, lead to poor outcomes and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report changes of condition (COC, major decline or improvement in a resident's status that will not resolve itself without intervention) to the physician for two of six sampled residents (Residents 17 and 126) by failing to:Report Resident 17's multiple, consecutive Restorative Nursing Aide (nursing aide program that helps residents maintain any progress made after therapy intervention to maintain their function) refusals in April 2026 to the physician in accordance with the facility's Policy and Procedure (P/P) titled, Change in a Resident's Condition or Status. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect residents' right to privacy when computer screens were left open and unattended displaying the residents' personal and medical information on the computer screens for three of the three residents (Residents 46, 81, and 105) according to the facility's policy and procedures (P&P - policy explains the rules and presents them in a logical framework while procedures outline the step-by-step implementation of various tasks) titled Resident Rights with a revision date of 1/29/2026, and the facility's P&P titled Confidentiality of Information and Personal Privacy with a revision date of 1/29/2026 This deficient practice had the potential to result in unauthorized person to view personal and medical information for Residents 46, 81, and 105.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one out of one sample resident (Resident 126) was free from unnecessary physical restraint (a device or method used to limit a patient's movement to prevent self-harm or harm to others), by failing to ensure:1. Resident 126's left side of the bed was not pushed against a wall, and a bedside table and a Merri walker (ambulation device designed for individuals with balance, mobility, or cognitive impairments) was not placed on Resident 126's bedside table right lateral side to prevent Resident 129 from getting out of bed and ambulating (walking).2. Obtain a physician's order for the Merri walker for Resident 126. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure the assessment entries on the Minimum Data Set (MDS- an assessment and care screening tool) related to Pre -admission Screening and Resident Review (PASRR -a safety check done before someone enters a Medicaid-certified nursing home to ensure the facility can meet their specific needs, or if they would be better served in the community) was accurately documented [NAME] to the facility's policy and procedure (P&P) titled Certifying Accuracy of the Resident Assessments, dated 1/21/2026 for two of two sampled residents (Resident 5 and Resident 127). This deficient practice had the potential to negatively affect the plan of care and delivery/provision of necessary care and services for Resident 5 and Resident 127.

Inspectors wroteBased on interviews and record reviews the facility failed to submit the required complete information contained in the Minimum Data Set (MDS- standardized data collection tool used to assess cognitive and functional status, and care needs) for one of 27 sampled residents (Resident 4) within 14 days after discharge/expiration date ([DATE]) to the Centers for Medicare & Medicaid Services (CMS: a federal agency within the United States Department of Health and Human Services) System. This deficient practice had the potential for Resident 4's death to go unreported.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately assess and code the Minimum Data Set (MDS, a resident assessment tool) assessments for three of 11 sampled residents (Residents 47, 2, and 105) according to the facility's policy and procedures (P&P) titled, Resident Assessments, revised 1/29/202, by failing to:1. Ensure the section relating to insulin (a hormone that lowers the level of glucose (a type of sugar) in the blood) use for Resident 47 was accurately coded.2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that a pre-admission screening Resident Review (PASRR -a detailed assessment that determines if someone with a mental illness [like serious mental illness, intellectual disability, or related conditions] needs specialized services and the most appropriate place to receive them) level II for residents identified with mental disorder were evaluated to receive care and services in the most integrated setting appropriate to their needs for one of two sampled residents (Resident 11), in accordance with the facility's policy and procedures (P&P) titled PASRR Completion Policy with review date of 4/15/2026. This deficient practice had the potential to negatively affect the appropriate care and services rendered and required for Resident 11.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment and services to improve two of six sampled resident's (Resident 17 and 126) abilities to carry out activities of daily living (ADL, basic activities such as mobility, eating, dressing, toileting, and communicating) by failing to:Ensure staff assisted Resident 17 out of bed daily to maintain and improve mobility (ability to move). 2. Ensure Resident 126 who had communication difficulties and a language barrier was provided access to a communication aid (tool designed to assist persons with speech and language difficulties in expressing their needs and understanding to others) and/or alternative communication strategies to facilitate communication with residents and staff. [...]

Inspectors wroteBased on interview and record review, for two of two sampled residents (Resident 11 and Resident 105), the facility failed to:1. Transfer Resident 11 to General Acute Care Hospital (GACH -full service community hospital) on 2/13/2026. Resident 11 experienced a change of condition (COC - a significant deviation in a person's health, functional status that requires timely recognition, response to prevent complication or death) on 2/13/2026, according to physician's order dated 2/13/2026, and the facility's policy and procedures (P&P) titled Change in a Residents Condition or Status with review date of 1/29/2026. 2. Notify the physician and document why the facility did not transfer Resident 11 to GACH until 2/14/2026. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that low air loss mattress (LAL -a medical-grade mattress that prevents and treats pressure ulcers [bedsores] by constantly blowing air through tiny holes in the fabric, keeping the patient's skin cool and dry) guidelines were adhered to for appropriate pressure redistribution support in accordance with the facility's policy and procedures (P&P) titled Support Surface Guidelines dated 1/29/2026, for one of one sampled residents (Resident 80). This deficient practice had the potential to significantly compromise Resident 80's safety, leading to serious skin breakdown, infection, increased discomfort and hospitalization.

Inspectors wroteBased on interview and record review the facility failed to provide treatments and services to maintain or improve mobility (ability to move) and Range of Motion (ROM, full movement potential of a joint) for two of six sampled residents (Residents 50 and 105) with ROM and mobility concerns. 1. For Resident 105, the facility failed to: a. Objectively (evaluating or viewing something based solely on observable facts, measurements, and evidence) measure both of Resident 105's knees, shoulders, elbows, wrists, and hands during the Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) and Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday activities) evaluations, dated 2/18/2026. b. [...]

Inspectors wroteBased on observation, interview, and record review, for one of six sampled residents (Resident 126) identified as a high fall risk, was supervised and wore a helmet when walking in the hallway in accordance with physician's orders dated 5/2/2026. These deficient practices placed Resident 126 at risk for repeated falls and injury, pain, and a decline in overall physical functioning.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one out of one sampled Residents (Residents 147) received lidocaine external patch (a topical, medicated adhesive patch that delivers the local anesthetic lidocaine directly through the skin to the nerves) 5 percent (%-unit of measurement) according to physician's orders and the facility's policy and procedures (P&P) titled Administering Medications dated 1/29/2026. These deficient practices resulted in the Lidocaine External Patch 5% patches left on Resident 147 right elbow and outer left ankle in excess of 12 hours (hrs) with the potential for undesired complications not limited to Lidocaine External Patch 5% dose buildup, skin irritation, dizziness, confusion, or serious health complications, hospitalization, and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff provide specialized rehabilitative services (Rehab, services that require specialized training and experience of a licensed therapist or therapy assistant), Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function), and Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) evaluations for one of six sampled residents (Residents 17) in accordance with physician's orders, dated 4/4/2026. These deficient practices prevented Residents 17 from receiving skilled Rehab services to maintain, improve, and achieve his highest practicable level of function.

Inspectors wroteBased on interview and record review, the facility failed to ensure all Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) and Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) therapy records prior to 2/2026 were systematically organized and readily accessible for three of six sampled residents (Residents 17, 50, and 105). This deficient practice had the potential to delay and negatively affect the delivery of necessary care and services.

Inspectors wroteBased on interviews and record review, the facility failed to follow their policy and procedures (P&P) titled, Care Plans [a written step by step outlining a specific health or personal care needs and actions with goals to be med], Comprehensive Person-Centered, with a review date of 1/29/2026 for one of the three sampled residents (Resident 1). By failing to develop and implement a care plan for Resident 1 who was admitted with a history of falls and identified as a moderate risk for falls on 1/2/2026. As a result of this deficient practice Resident 1 had a fall on 3/17/2026 as well as an injury of unknown origin on 4/28/26.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain clean and sanitary ventilation intake screens for two of seven sampled residents (Resident 5 and 6). This failure resulted in extensive dust buildup on the ventilation intake screens and had the potential to expose residents to allergens (a substance that can cause an allergic reaction). During a concurrent observation and interview on 3/24/26 at 10:35 AM with Resident 5 in Resident 5's room, the intake screen for the ventilation system above the foot of her bed was observed covered with a thick layer of dust. The resident verified this and stated it has been like that for quite a while and she would not want the dust to fall on her and then inhale it. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident's refrigerator/ freezer storage P&P was followed by failing to ensure:The resident nutrition room cabinets were free from undated and unlabeled open box of cornflakes and bag of potato chips and all food in the resident's refrigerators were labeled and dated properly as well as the food being stored in a manner that would provide air circulation. During an observation with concurrent interview on 3/20/26 at 1:07 pm with Infection Preventionist Nurse (IPN) in the 2nd floor nutrition room, a cabinet was observed with undated and unlabeled open box of corn flakes and bag of potato chips. The IPN removed the items from the cabinets and stated they should not be stored there and should be labeled with the resident name and date of expiration everything should have a date name and date it was opened. [...]

Inspectors wroteBased on interview, and record review, facility failed to ensure the staff assisting English-only speaking residents were not speaking in a language the residents did not understand when providing care for two of seven sampled residents (Resident 3 and 5). This failure resulted in Resident 3 and 5's primary language not being respected and used in front of the residents and had the potential to affect the resident's communication and understanding with the staff. During a review of Resident 3's admission Record (AR), dated 3/24/26, indicated the resident was admitted to the facility on [DATE], with diagnoses including hypertension (HTN - high blood pressure), anemia (a condition where the body does not have enough healthy red blood cells) hemiplegia (weakness of one side of the body) and hemiparesis (paralysis of one side of the body) following cerebral infarction (stroke). [...]

Inspectors wroteThe facility failed to follow the resident's care plan of wandering risk for one of seven sampled residents (Resident 7). This failure resulted in Resident 7 having an elopement incident on 3/10/26 at 3:20 am. During a review of Resident 7's AR dated 3/25/26 indicated, the resident was admitted to the facility on [DATE], with diagnoses encephalopathy (a broad term for any diffuse disease, damage, or malfunction of the brain that alters its structure or function), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), epilepsy (a chronic neurological disorder characterized by recurrent, unprovoked seizures caused by sudden, abnormal electrical activity in the brain), schizophrenia (a mental illness that is characterized by disturbances in thought), and anemia. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to handle linen according to the facility's policy and procedures titled, Departmental (Environmental Services) Laundry and Linen reviewed 6/2/2025. This deficient practice places all residents in the facility at risk for infection.

Inspectors wroteBased on observations, interview and record review the facility failed to ensure facility staff implemented the facility's policy and procedures (P&P) titled, Assisting the Resident with in-room meals reviewed 6/2/2025, for three of three residents (Residents 1, 3, and 4) by failing to:Assist Residents 1, 3, and 4 with feedingDocument meal intake percentages according t, Residents 1, 3 and 4. Ensure Certified Nursing Assistant (CNA) 1 reported/notified to a licensed nurse (Licensed Vocational Nurse [LVN] and or Registered Nurse [RN] when Resident 1 had decreased meal intake. These deficient practices had the potential to cause inadequate nutrition, choking and or weight loss for Residents 1, 3, and 4.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four residents (Resident 1) was free from any significant medication error by failing to notify a physician when a resident refused to take two antipsychotic medications (medications to treat mental illness) three consecutive times according to the facility's policy and procedures (P&P - policy explains the rules and presents them in a logical framework while procedures outline the step-by-step implementation of various tasks) titled Preparation and General Guidelines with a revision date of 12/2019. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a reliable transportation arrangement for a resident to receive medically required dialysis treatment (process of removing waste products and excess fluid from the body using a machine when the kidneys are not able to do so) for one of five sampled residents Resident 5. This failure resulted in Resident 5 missing three medically necessary dialysis treatments on [DATE], [DATE] and [DATE] and placed the resident at risks for potentially serious unwanted outcomes. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the resident and resident's responsible party received changes in coverage made to services and share of cost (SOC) were provided periodically for one of four sampled residents, Resident 2. This deficient practice resulted in Resident 2's responsible party/POA not being able to exercise their rights to file for appeal and take timely action for bills past due since September 2025.

Inspectors wroteBased on observation, interview, and record review the facility staff failed to perform hand hygiene while caring for one of seven sampled residents (Resident 7). This deficient practice had the potential to spread infection to residents.

Inspectors wroteBased on interview and record review the facility failed to develop a discharge care plan for three of three sampled residents, (Residents 1, 2 and 3). This deficient practice has the potential to result in Residents 1, 2, and 3's needs not been met. A review of Resident 1's admission record indicated the facility admitted this [AGE] year old female on 2/19/2025 with diagnoses including left humerus fracture (broken arm), generalized muscle weakness, encephalopathy (broad term to describe any disease, damage or change that alters brain function), cystitis (bladder infection), bilateral osteoarthritis of knee (a progressive disorder of the joints, caused by a gradual loss of cartilage), Anxiety (feeling of fear or unease), hypertension (high blood pressure), major depressive disorder (persistent sadness) and repeated falls. [...]

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of verbal abuse (any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to patients or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability), for one out of two sampled residents (Resident 1) to the Department of Public Health and Ombudsman (an official appointed to investigate individuals' complaints against maladministration) in accordance with the facility's policy and procedures (P&P) titled, Abuse Investigation and Reporting, reviewed 1/21/2025, within 2 hours after the facility became aware of the abuse allegation on 11/27/2025. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide social services to four out of six sampled residents (Resident 1, Resident 3, Resident 4, and Resident 5) by failing to have the Social Services Director (SSD) assess the residents' psycho-social well-being after the residents' were involved in physical and/or abuse allegations. On 11/27/2025, Resident 1 alleged Resident 2 hit him on the leg the previous day and Resident 1 called law enforcement to investigate. On 11/29/2025, the Activity Assistant (AA) witnessed an episode of verbal abuse when Resident 4 called Resident 3 an invective while passing Resident 4 and Resident 4 addressed Resident 3 as a curse word in return. On 12/5/2025, Resident 5 alleged Resident 6 hit Resident 5 on the wrist. This deficient practice had the potential for the residents' psychosocial needs to go unaddressed. a. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide reasonable accommodation of needs for two of three sampled residents (Resident 4 and Resident 5), by failing to ensure Resident 4 and Resident 5's call light (a device with a button or touchpad a resident uses to set off an alarm that flashes/rings to alert the facility staff the resident needs assistance) was answered in a timely manner, as per the facility's Policy and Procedures (P&P) titled Answering the Call Light revised on 11/26/2025. This deficient practice had the potential for Resident 4 and Resident 5 not to receive emergency care or have a delay in care and services that could result in a fall or accident.

Inspectors wroteBased on interviews and record review the facility failed to supervise and monitor the whereabouts of one of four residents (Resident 1). On 9/05/2025 the facility admitted Resident 1 from a general acute care hospital (GACH) with diagnoses including hearing voices to kill himself and verbalized to Registered Nurse (RN) 1 and Licensed Vocational Nurse (LVN) 1 that he wanted to leave the facility. This deficient practice resulted in Resident 1 eloping (the unauthorized departure of a patient from a healthcare facility without notifying staff or receiving proper discharge) from the facility on 9/06/2025 after 8:30 AM without notifying any facility staff. Resident 1's whereabouts remain unknown.

Inspectors wroteBased on observation, interview, and record review the facility maintenance failed to report nonfunctioning thermostats to facility administration for three of three sampled residents (Residents 1,2 and 3). This deficient practice caused the facility maintenance to turn off the air conditioning unit at night as they were unable to regulate the temperatures in the building leaving residents to complain about the heat. On 8/20/2025 and 9/2/2025 The California Department of Public Health (CDPH) received anonymous complaints alleging the facility's air conditioning was not functioning properly; and the facility was turning off the air conditioning which caused the temperature to be warmer at night. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the resident's right to be free from mental abuse (intentional, willful, or reckless verbal or nonverbal action) and physical abuse (deliberate aggressive or violent behavior with the intention to cause harm) for two of four sampled residents (Residents 2 and 3) by failing to: 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to keep the nursing station phone ringer on a volume that could be heard and answered for four of four nursing stations. This failure had the potential to limit/miss communication with doctors, family members, and staff. During an observation and a concurrent interview on 8/23/25 at 1:30 pm by nursing station three (3) a call from the main facility phone line was made and transferred to nursing station 3, the phone was noted to not be ringing at the station. An overhead page was heard to answer the phone at nursing station 3 and Licensed Vocational Nurse (LVN) 1, answered the phone. LVN 1 states and verifies the phone volume was down all the way and was unable to hear the phone ring. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide intravenous (IV, access to the bloodstream via a vein) access care as per facility's policy and procedures (P&P) for one of three sampled residents (Resident 1), by failing to ensure IV therapy fluids were infused over 20 hours, as ordered. This failure resulted in a delay in IV fluid infusion and had the potential to affect Resident 1's electrolytes (minerals in your blood and other body fluids that carry an electric charge, regulating your body's function). [...]

Inspectors wroteBased on interview and record review the facility failed to explain and obtain a signature for the admission agreement upon an admission per its policy and procedures (P&P) for one of three sampled residents (Resident 1). This deficient practice had the potential to result in a knowledge deficit as to which covered services were provided by the facility verses Resident 1's insurance.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from physical abuse for one of four residents (Resident 1) by Resident 2. Resident 1 had a behavior of wandering behavior into other residents' rooms. The facility failed to:- Develop a comprehensive care plan (a plan of care that summarizes a resident's health conditions, specific care needs, and current treatments) to address Resident 1's wandering, per the facility's policy and procedure (P&P) titled, Wandering and Elopements. - Accurately assess Resident 1's risk for wandering upon admission- Adequately monitor Resident 1's location to ensure the resident's safety and prevent the resident from wandering into other resident rooms. - Provide a safe environment for Resident 1 As a result, On 7/6/2025, Resident 1 wandered into Resident 2's room and ate Resident 2's sandwich. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement their policy regarding reporting of a resident-to-resident altercation and to submit a conclusion report of investigation within five days or in accordance with state or federal law for two of three sampled residents (Resident 1 and 2). This resulted in a delay in an onsite inspection by the Department of Public Health to ensure the residents' allegation of abuse was investigated, which can also lead to a delay in prevention of further abuse.

Inspectors wroteBased on interview, and record review, the facility failed to provide necessary respiratory care services for one of three sampled residents (Resident 4), by failing to follow physician's order for bilevel positive airway pressure machine (BiPAP - a device that helps people breathe easier, especially when they have breathing difficulties like sleep apnea [a sleep disorder where breathing repeatedly stops and starts during sleep]) per facility's protocol. This deficient practice had the potential to cause complications associated with respiratory treatment.

Inspectors wroteBased on observation, interview and record review the facility failed to: 1. Answer call light in timely manner for one of three sampled residents, Resident 1, 2. Provide a director of staff development (DSD-a professional who oversees and manages the training and development activities for employees within an organization) to train staff, and 3. Ensure the certified nursing assistants (CNA) from the registry (an agency the provides CNA's to health care facilities on a temporary, as needed basis to fill their staffing needs) were competent to provide care for one of three sampled residents, Resident 2. These deficient practices placed the residents' safety at risk

Inspectors wroteBased on observation, interview and record review for 6 of 7 Residents sampled, Residents 1,2,3,4,5 and 6. The facility failed to provide a physical therapist (PT-healthcare professional who helps people improve or restore mobility and reduce pain) to perform initial evaluations (a comprehensive assessment conducted by a licensed PT to understand a patient's physical condition and movement limitations). This deficient practice placed these residents at risk of a decline in mobility.

Inspectors wroteBased on interview and record review the facility failed to open the dining room for dinner to all residents every day. This deficient practice is a violation of resident's rights.

Inspectors wroteBased on observation, interview and record review the facility failed to provide enough staff to have the dinning room open for all meals. This deficient practice placed all residents at risk of .

Inspectors wroteBased on interview and record review, the facility failed to implement their policy regarding reporting of an employee to resident altercation and to submit a conclusion report of investigation within five days or in accordance with state or federal law for one of four sampled residents (Resident 2). This resulted in a delay in an onsite inspection by the Department of Public Health to ensure the residents' allegation of abuse was investigated which can also lead to a delay in prevention of further abuse for Resident 2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to employ a full-time Physical Therapist to provide a specialized rehabilitative service to 144 residents bed-capacity in the facility that may need a physical therapy evaluation and treatment. This deficient practice may result in delayed treatment and services and placed the residents at higher risk for further decline.

Inspectors wroteBased on interview and record review, the facility failed to employ a qualified social worker on a full-time basis that met the qualifications specified in the regulation. This deficient practice had a potential for 144 bed capacity of residents residing in the facility not being assisted and receiving medically related necessary care to attain highest practicable well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident's call light (a device used to notify the nurse that the resident needs assistance) were answered promptly for one of six sampled residents (Resident 6). This deficient practice had the potential to result in the residents not being able to summon staff for assistance for care and services as needed, which could lead to accidents such as falls with injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to use two people to transfer a resident (Resident 1) from bed to wheelchair, using a Mechanical lift (Hoyer lift - sling lift, an assistive device that allows residents to be transferred between a bed and a chair, by the use of electrical or hydraulic power) instead only using one person for one of six sampled residents. This placed Resident 1 at risk for falls or accidents during use of the mechanical lift and can lead to injuries including possible fractures.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of verbal abuse (any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to patients or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability), for one of two sampled residents (Resident 1) to the Department of Public Health and Ombudsman (an official appointed to investigate individuals' complaints against maladministration) within two hours after the allegation occurred on 4/5/2025 in accordance with the facility's policy and procedures (P&P) titled, Abuse Investigation and Reporting. This failure had the potential to delay of an onsite inspection by the California Department of Public Health (CDPH) and the Ombudsman to ensure Resident 1's circumstance were investigated. [...]

Inspectors wroteBased on observation, interview, and record review for one of three sampled Residents, Resident 1. The facility failed to develop interventions to stop resident 2 from allegedly verbally abusing Resident 1. This deficient practice places Resident 1 at risk for continued verbal abuse from Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to develop a care plan for history of liver transplant for one of five sampled residents (Resident 2). This failure resulted in no plan of care for Resident 2's history of liver transplant and had the potential to affect continuity and delivery of care to meet the resident's needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to meet professional standards to: 1. Ensure communication of high risk for elopement (the act of leaving a facility unsupervised and without prior authorization) was made for one of two sampled residents (Resident 1). 2. Ensure one of two sampled residents (Resident 1) was wearing an identification (ID) wristband. These deficient practices had the potential to affect the resident's safety and wellbeing during medication administration, delivery of services and monitoring of wandering and elopement.

Inspectors wroteBased on observation and interview the facility failed to follow physician's orders regarding skin tear (traumatic wounds caused by friction when the upper layer of the skin becomes torn from the underlying layers) treatment for one of two sampled residents (Resident 1). This deficient practice had a potential for retearing and delayed healing of the skin tear on the resident's right wrist/ hand.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure communication of high risk for elopement (the act of leaving a facility unsupervised and without prior authorization) was made for one of two sampled residents (Resident 1). 2. Ensure one of two sampled residents (Resident 1) was wearing an identification (ID) wristband. This failure had the potential to place the resident at risks for elopements and other accidents affecting resident's safety during delivery of services and monitoring of wandering and elopement.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident, who was assessed as risk for falls, did not fall and sustained injury for one of four residents (Resident 1). The facility failed to: 1. Ensure Resident 1 was supervised and monitored to prevent repeated falls and injuries from 9/13/2024 to 3/15/202 per care plan titled; Falling Star dated 9/13/24. 2. Revise and evaluate the effectiveness of interventions of Resident 1's care plan titled, Falling Star Program, dated 9/13/24 after Resident 1 was found on floor11/14/2024, to prevent Resident 1 from future falling. 3. Ensure there was no urine on the floor by the Resident 1's bedside that led Resident 1 to slip on the paddle of urine and fall. 4. [...]

Inspectors wroteBased on interview and record review, the facility staff failed to: 1. Notify the physician (MD) when one of three sampled residents (Resident 2) had change of condition (COC/CIC) 2. Documented that Resident 2 had complained of a sore throat, swallowing issues, and body itching. These deficient practices had the potential to result in possible delayed provision of necessary care and services to Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to ensure document grievances per facility policy for one of three sampled resident (Resident 2). This deficient practice violated Resident 2 and Resident 2 ' s family member (R2FM) right to have grievance addressed and had a potential to delay any necessary care and services for Resident 2.

Inspectors wroteBased on interview and record review the facility failed to protect two of three sampled residents (Residents 2 and 3) from misappropriation (the unauthorized, improper, or unlawful use of funds or other property for purposes other than that for which intended) of property and personal belongings by failing to: 1. Inventory and document belongings upon admission and discharge for Resident 2. 2. Release Resident 3's belongings to Resident 3 or the Resident 3 ' s representatives when Resident 3 was transferred to general acute care hospital (GACH). These deficient practices: 1. Resulted in Resident 3 not receiving all belongings. 2. Had the potential to loose Residents 2 and 3 belongings.

Inspectors wroteBased on interview and record review, the facility failed to ensure baseline care plan was developed and implemented within 48 hours of admission for one of six sampled residents (Resident 2). This deficient practice had the potential to negatively affect the provision of care and services for Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to provide reasonable accommodation of resident needs and preferences for four of six sampled residents (Resident 4, 5, 6 and 7) by failing to: 1. Ensure television (TV) was working at all times for Resident 4, 5 and 6. 2. Ensure hot water was available throughout the day during showers for Resident 4, 5, 6 and 7. These deficient practices had the potential to negatively impact the psychosocial well-being of the residents and had the potential to delay necessary care for Residents 4, 5, 6 and 7.

Inspectors wroteBased on interview and record review, the facility failed to ensure protection of resident ' s rights to privacy for one of five sampled residents (Resident 5) by failing to ensure Resident 5 received unopened mail. This deficient practice violated Resident 5 ' s right to privacy.

Inspectors wroteBased on interview, and record review, the facility failed to ensure sufficient nursing staff was available to provide nursing and related services to meet the resident ' s needs safely and in a manner that promotes each resident ' s rights, physical, mental, and psychosocial well-being for one of six sampled residents (Residents 4) by failing to ensure call light was answered promptly for Resident 4. This deficient practice has the potential to affect the quality of life and had the potential to delay necessary care for Resident 4.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a licensed administrator was appointed by the Governing Board. This failure had the potential to affect resident care and management of the facility.

Inspectors wroteBased on observation, interview, and record review, for one of six sampled residents (Resident 1) who was a fall risk, deaf, and blind, the facility failed to ensure: 1) Resident 1 was supervised to prevent falls 2) The bed alarm (is an effective device that alerts caregivers when someone attempts to get out of bed. It typically works with a sensor pad placed under the mattress or sheets that detects pressure) was transferred with the Resident 1 and was activated/functional when Resident 1 was transferred to another room. These deficient practices resulted in Resident 1 falling on 2/07/2025 and sustaining a small cut on the forehead and a fracture (break in a bone) to the right hip bone near hip prosthesis (a device that replaces or enhances a missing or impaired body part). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of six residents ' (Resident 1) family member representative (FMR) 1, received copies of Resident 1 ' s medical records within two days of the request. As a result, FMR1 requested the facility for copies of the medical records four times causing FMR1 to become frustrated. As of 2/25/2025, FMR1 had not received requested medical records for Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure staff did not placed their personal monster energy drink in the refrigerator in the kitchen. 2. Staff performed hand hygiene after leaving the patient's room that was on isolation and after disposing of dirty linen from a resident's room. 3. Ensure standard infection control practices were followed for four (2) out of 23 sampled residents (Residents 21 and 227) by: a. Failing to ensure oxygen nasal cannula tubing (a device used to deliver supplemental oxygen placed directly on a resident's nostrils) were off the floor for Resident 21. b. Failing to ensure nebulizer (nebulizer is a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) was securely wrapped in a clear plastic cover and not touching the bedside table for Resident 227. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's clinical records were complete and updated concerning advance directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) for four out of four sampled residents (Residents 72, 27, 65 and 114) by failing to maintain an accurate and current copy of the resident's advance directives in the resident's clinical record. This failure had the potential to cause conflict with a resident's wishes regarding health care.

Inspectors wroteBased on observation, interview, and record review the facility failed to reinforce the residents right to a safe and homelike environment for two of seven sampled residents (Resident 18 and Resident 118). 1. For Resident 18 the facility failed to replace a scortched black mark on the wood floor near the foot of Resident 18's bed 2. For Resident 18 the facility failed to inventory the resident's personal belongings. 3. For Resident 118, the facility failed to repair damaged wall and paint the wall behind the resident's bed. This failure resulted in the loss of Resident 18's personal checks, and Resident 118 feeling ashamed of living with damaged and unpainted walls. in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. Nursing staff and the certified nurse assistant (CNA) are competently wearing N95 masks (is the most common of the seven types of particulate filtering facepiece respirators. This product filters at least 95% of airborne particles) during an ongoing influenza outbreak in the facility. 2. The director of staff development (DSD), a licensed vocation nurse (LVN) had the skill set to train registered nursing staff concerning resident care and assessment for abuse reporting during in-service training. These deficient practices had the potential to result in: 1. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that one of 23 sampled residents (Resident 20) was free of unnecessary medication by failing to clarify the physicians order for Amoxicillin (a drug used to treat infections caused by bacteria and other microorganisms), to be administered orally (by mouth) for 120 days. This deficient practice resulted in Resident 20 receiving an excessive dose of antibiotics, for an excessive duration without adequate indication for prolonged use, rationale or monitoring and had the potential to result in adverse consequences such as antibiotic resistance, kidney, and liver failure.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen for 114 of 114 residents who received food from the kitchen. By failing to ensure: 1. The Italian and ranch dressings were not unlabeled and undated, 2. The bacon slices was not uncovered and undated. 3. The leftover chicken and ground beef stored in the refrigerator had record of following the cool down method. 4. The 16 pre-packed sandwiches were not undated. 5. The meat slicer was uncleaned. These failures had the potential to result in harmful bacteria growth and cross contamination (a transfer of harmful bacteria from one place to another or one object to another) that could lead to foodborne illness (illness caused by food contaminated with bacteria, viruses and other toxins).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe homelike environment by not equipping corridors with firmly secured handrails on each side. This deficient practice had the potential to result in a fall causing injury to a resident using the unsafe railing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff wear identification (ID - a card that identifies a person/staff) badges while on the nursing floor providing nursing care to the residents. This deficient practice had the potential for: 1. Residents to decline nursing care from staff who they cannot identify causing residents to miss the nursing care they need. 2. Residents to fear for their safety when staff did not have proper identification causing residents to feel unsafe while residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow the facility's Use of Restraints, policy and procedures for one of 23 sampled residents (Resident 12) by failing to: 1. Execute an informed consent for restraints prior to administration 2. Conduct a pre-restraining assessment 3. Initiate a flow sheet documenting restraint site, observation, range of motion, and repositioning and every two-hour release of the physical restraint These deficient practices have the potential to place the residents at risk for unnecessary prolonged use of restraints, a decline in physical functioning and skin injuries.

Inspectors wroteBased on observation, interview, and record review, the Facility failed to ensure a care plan was initiated for one out of 23 sampled residents (Resident 20) for amoxicillin (antibiotic - medication to treat infection/s) ordered for 120 days to treat oral lesions (abnormal cell growths or sores in the mouth that can be painful). This deficient practice had the potential to negatively affect the delivery of care and services and had the potential to result in complications from unnecessary medications such as resistance to antibiotics and a super bag infection (a microorganism/bacteria that has become resistant to antibiotics or antifungal medications). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 5), who had limited range of motion (ROM - the extent of movement of a joint) in the right hand received Restorative Nursing Aide (RNA - assistant that help residents to maintain their function and joint mobility) services as ordered by the physician. This deficient practice put Resident 5 at risk for further decline and contracture formation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one out 23 sampled residents (Resident 277) was evaluated and demonstrated the ability to self-administer medication prior leaving medication at the Residents bedside. This deficient practice had the potential to result in an allergic reaction, poor patient outcomes and even death from accidental ingestion of unknown medication/substance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident with an indwelling urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) received catheter care as ordered by the physician for one of two sampled residents (Resident 55). This deficient practice had the potential to result in urinary tract infections (UTI- is an infection of the urinary tract, which includes the kidneys, bladder, ureters, and urethra) for Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary respiratory care services for two of three sampled residents (Resident 21 and Resident 39). 1. Resident 39 the facility failed to administer two liters of oxygen continuously according to physician's order and failed to date the resident's nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen). 2. The facility failed to ensure Resident 21 received the correct therapeutic dose (of oxygen (a colorless, odorless gas that is essential for life and the proper functioning of the body) as ordered by the physician. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe and functioning environment in the resident care area as evidenced by the following: 1. Two occupied resident beds in room [ROOM NUMBER] A and B were observed the mechanical part to lift vertically up and down, to lift the head of bed up and down were not functioning. 2. A maintenance Work Sheet for December 2024 and January 2025 indicated multiple bed remotes and call lights repair requests. 3. Facility staff observed routinely disabling emergency exit alarms located at the corner of Station 1 and 2 on 2nd Floor and Station 3 and 4 on 3rdfloor of resident care areas while utilizing emergency exits. These failures have the potential to put residents at risk for fall and injury, unauthorized person accessing resident care areas, and fire safety risks for residents and staff.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Treatment Administration Record (TAR) was accurate and complete for two of two sampled residents (Residents 1 and 2). This failure resulted in an inaccurate and incomplete medical record and had the potential to affect the pressure ulcer/injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) healing.

Inspectors wroteBased on observation, interview, and record review the facility failed to have soap available in soap dispenser in kitchen and the [NAME] failed to perform hand hygiene in between glove change while preparing lunch. These deficient practices placed all residents at the facility at risk of infection due to poor hand hygiene.

Inspectors wroteBased on interview and record review the facility failed to report an allegation of physical abuse for one of three sampled Residents (Resident 1). This deficient practice left Resident 1 and others at risk for potential abuse.

Inspectors wroteBased on interview and record review the facility failed to keep two of three sampled resident's room free of roaches, (Residents 1 and 3). This deficient practice placed all residents at risk of roach infestation.

Inspectors wroteBased on interview and record review, the facility failed to ensure a request for documents was fulfilled in a timely manner for one of three sampled residents (Resident 1) when the facility did not provide the requested documents to Resident 1's representative (RR) within the timeframes specified in the facility's policy and procedures (P&P) titled Release of Information. This deficient practice violated the right of the RR to have access to Resident 1's medical records and the potential to cause undue concern and anxiety on behalf of the resident.

Inspectors wroteBased on interview and record review the facility failed to notify the resident representative (RR) of an accident for one three sampled residents (Resident 1). This deficient practice violated the right of the RR to be informed of the Residents' condition.

Inspectors wroteBased on observation, interview, and record review the facility failed to administer Losartan Potassium (medication used to treat high blood pressure) 25 milligrams (MG) for hypertension (High blood pressure) for one of three sampled residents, Resident 2 as per Physician order dated 9/22/2024. As a result, Resident 2 did not receive Losartan Potassium from 9/22/2024 to 9/25/2024. Placing Resident 2 at risk for elevated blood pressure which could cause a stroke (an emergent condition in which ruptured blood vessels in the brain can bleed due to high blood pressure).

Inspectors wroteBased on observation, interview, and record review for one of four sampled residents (Resident 4), the facility failed to: 1) Ensure Certified Nursing Assistant 5 (CNA 5) immediately reported Resident 4 ' s injuries of unknown origin to the forehead and the left cheek to Licensed Vocational Nurse 6 (LVN 6) when CNA 5 noticed Resident 4 ' s injuries on 8/02/2024. 2) Ensure LVN 1, LVN 2 and LVN 5 immediately notified a physician, Medical Doctor 1 (MD 1), the Director of Nursing 1 (DON 1) and or the Administrator that Resident 4 had injuries of unknown origin to the forehead and the left cheek on 8/02/2024 at 7:05 AM, 8/04/2024 between 4:30 PM and 5 PM, and on 8/04/2-24 at 11 PM. These deficient practices resulted in three days and four hours delay of necessary medical services for Resident 4.

Inspectors wroteBased on observation, interview, and record review for one of four sampled residents (Resident 4), the facility failed to ensure: 1) Certified Nursing Assistant 5 (CNA 5) immediately reported Resident 4's injuries of unknown origin to the forehead and the left cheek to Licensed Vocational Nurse 6 (LVN 6) when CNA 5 noticed Resident 4's injuries on 8/02/2024. 2) Licensed Vocational Nurses 1, 2, and 5 (LVN 1, LVN 2 and LVN 5) immediately notified a physician, Medical Doctor 1 (MD 1), the Director of Nursing (DON) and or the Administrator (Admin 1) that Resident 4 had injuries of unknown origin to the forehead and the left cheek on 8/02/2024 at 7:05 AM. These deficient practices resulted in three days and four hours delay of reporting to the officials in accordance with the State law.

Inspectors wroteBased on observation, Interview and Record Review the facility failed to: a. Place call light within reach for one of four sampled residents, (Resident 1). b. To answer call light timely for one of four residents, (Resident 3). c. Ensure call system is functioning for one for four sampled residents, (Resident 4) These deficient practices placed Residents 1, 3, and 4 risk for accidents.

Inspectors wroteBased on observation, Interview and Record Review the facility failed to provide reasonable access to a telephone for one of four sampled residents, Resident 1. This deficient practice is a violation of Resident 1's right to access to a telephone.

Inspectors wroteBased on interview and record review, the facility failed to ensure three sampled Certified Nursing Assistants (CNAs) and two sampled Licensed Vocational Nurses (LVNs) had the specific competencies and skill sets necessary to care for one of four sampled residents (Resident 1). This deficient practice resulted in the dislocation of Resident 1's left tibia proximal to the femur.

Inspectors wroteBased on observation, interview, and record review the facility failed to apply non-rebreathing oxygen mask (NRM- a mask with a small bag (reservoir bag) attached that fills with oxygen when connected to a tank and delivers high flow oxygen, usually in an emergent situation) with the correct amount of oxygen for two of three sampled residents, (Residents 1 and 3). This deficient practice had the potential to have caused Residents 1 and 3 to be deprived of oxygen in an emergent situation and lead to a complaint being filed with the California Department of Public Health (CDPH).

Inspectors wroteBased on observation, interview, and record review the facility failed to display appropriate transmission-based precaution sign and follow appropriate transmission-based precautions, for one of three sampled residents, (Resident 2) These deficient practices had the potential to place residents, staff and visitors at potential risk of spread of infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide dressing change to stage 4 pressure ulcer of the sacrum (full thickness tissue loss with exposed bone, tendon, or muscle on the lower back) as per physician order for one of three sampled residents, Resident 2. This deficient practice placed Resident 2 at risk of decline in wound healing and possible infection.

Inspectors wroteBased on interview and record review the facility failed to ensure one of three sampled residents ' (Resident 1) had home health services arranged for the resident when discharged to a board and care (small private facility, usually with 20 or fewer residents where residents receive personal care and meals while staff is available around the clock). This failure resulted in Resident 1 not receiving ordered home health services during the days Resident 1 was at the board and care.

Inspectors wroteBased on interview and record review, the facility failed to assess the right lower leg with a short leg splint (SLS - a devise that holds/supports a fracture [broken bone] or dislocated bone in place) which is at risk to develop pressure injuries (are localized damage to the skin as well as underlying soft tissue, usually occurring over a bony prominence or related to medical devices) for one of three sampled residents (Resident 1). This deficient practice resulted in Resident 1's developing unstageable pressure-induced tissue damage (full thickness pressure injuries in which the base is covered by slough/eschar [dead tissues]) of the right lower leg related to a medical device (short leg splint). Cross Reference (F656, F697, and F842)

Inspectors wroteBased on interview and record review, the facility failed to meet professional standards of care and practice for one of three sampled residents (Resident 1) by failing to: 1. Ensure an orthopedic (specialty in medicine concerned with the correction or prevention of deformities [alteration in the natural form of a part, organ, or the entire body], disorders or injuries of the skeleton) appointment for Resident 1 ' s right ankle dislocation was ordered and scheduled within seven days per General Acute Hospital (GACH ' s) discharge summary when Resident 1 was admitted to the facility on [DATE]. 2. Ensure a physician order and proper documentation when Resident 1 ' s right leg medical device was removed on 12/21/2023. 3. Ensure physician treatment orders were signed via treatment administration record (TAR). [...]

Inspectors wroteBased on interview, and record review, the facility failed to maintain accurate medical record in accordance with accepted professional standards and practices for one of six sampled residents (Resident 1) by failing to: 1. Obtain a physician order to remove Resident 1 ' s right leg short leg splint (SLS). 2. Document that Resident 1 ' s right leg short leg splint (SLS) facility removed on 12/21/2023. 2. Sign Resident 1 ' s treatment administration record (TAR) after completing physician treatment orders 3. Ensure Resident 1 and or responsible person consented to treatment. These deficient practices had the potential to negatively impact the delivery of service provided to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure prompt attempt was made to resolve grievances for one of five sampled resident (Resident 1). This deficient practice violated Resident 1 ' s responsible party (R1 RP ' s) right to have grievances addressed.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive care plan that meets the care/services based on resident ' s individual assessed needs for one of six sampled residents (Resident 1) by failing to ensure Resident 1 ' s right short leg splint (SLS-provide support and stabilize injuries in legs, ankle and foot) care plan was developed and implemented per facility policy. This deficient practice resulted in Resident 1 ' s unstageable pressure-induced tissue damage (full thickness pressure injuries in which the base is covered by slough/eschar [dead tissues]) of the right foot related to a medical device (SLS).

Inspectors wroteDuring an interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), received the treatment and care in accordance with professional standards of practice, related to pain prevention and management by failing to ensure that Resident 1 ' s right soft leg splint (SLS-provide support and stabilize injuries in legs, ankle and foot) pain was addressed and treated for any underlying causes of the right leg pain. This deficient practice resulted in Resident 1 ' s right foot medical device related, unstageable pressure-induced tissue damage (full thickness pressure injuries in which the base is covered by slough/eschar [dead tissues]). Resident 1 was also started an antibiotic (medication to treat bacteria) therapy for the right foot wound cellulitis (bacterial skin infection). Cross Reference (F656, F686)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure prompt notify the physician about diet modification changes for one of three sampled residents (Resident 1) per facility ' s policy titled Interdisciplinary Referral. This deficient practice had the potential for Resident 1 to aspirate (choked) on the provided mechanical soft diet (A mechanical soft diet consists of any foods that can be blended, mashed, pureed, or chopped using a kitchen tool such as a knife, a grinder, a blender, or a food processor) instead of the recommended puree diet (foods you don't need to chew, such as mashed potatoes and pudding. Food can also be can also blended or strained to make them smoother. Liquids such as broth, milk, juice, or water may be added to foods to make them easier to swallow).

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure kitchen staff were trained and evaluated for competency skills as followed: a. Two (2) of 2 staff (Diet Aide (DA) 1 and DA2) and were not able to verbalize proper dishwashing procedures. b. One (1) of 1 staff (Cook 1) was not following the manufacturer's guidelines when checking the Quaternary Ammonium Compounds (QAC's a type of chemical that is used to kill bacteria, viruses, and mold) sanitizer concentration (levels should be maintained from 200-400 parts per million [ppm] for various food-contact surfaces) as per facility policy indicating to submerge the test strip for 10 seconds. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the facility's kitchen, by failing to: 1. Safely store, label, and discard expired food: a. Refrigerated food not labeled correctly and expired food was found in the walk-in refrigerator, resident's refrigerator in the second (2nd) floor Station 1 and resident's refrigerator in third (3rd) floor Station four (4). b. Uncovered four cups of ice in the resident's refrigerator in 3rd floor Station 4. 2. Ensure kitchen environment, equipment, servicing supplies, and utilities were in good repair, functioning, and kept clean. a. The facility's kitchen refrigerator had reach-in shelves and undercounter refrigerator shelves were cracked and rusted. b. There was no hot water in the kitchen. c. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the kitchen ice machine, the second (2nd) floor ice machine and the third (3rd) floor ice machine in a safe operating condition when staff made their own ice for resident's use and stored the ice in uncovered cups in the resident's freezer. This deficient practice had the potential to result in contamination of ice that could lead to foodborne illness in 93 of 93 medically compromised residents who received food from the kitchen.

Inspectors wroteBased on observation, interview and record review the facility failed to sit down at eye level while feeding during lunch for two of two sampled residents, (Residents 37 and 57). This deficient practice had the potential to cause aspiration (sucking food into an airway causing choking) by missing resident cues (signs that resident still has food in mouth or choking) due to not being eye level for Residents 37 and 57.

Inspectors wroteBased on observation, interview and record review the facility failed to order low air loss (LAL - A mattress designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) mattress for one of one sampled resident (Resident 16) with a re-opened stage 4 sacral coccyx (A large flat bone in the lower part of the spine) pressure ulcer (Localized skin and soft tissue injuries that form as a result of prolonged pressure and shear, usually exerted over bony prominences). This deficient practice may have caused sacral coccyx stage 4 pressure ulcer to worsen for Resident 16.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a medication error rate of less than 5 % (percent) during medication pass for 2 of 13 sampled residents (Resident 51 and Resident 249). This deficient practice had the potential to lead to a worsening in medical conditions, hospitalization and/or death.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow professional standards of practice for safe medication storage, medication ordering, and medication receiving by failing to: a. to check the expiration date of the emergency kit (e-kit - secured container or secured electronic system containing drugs which are used for either immediate administration to residents or in an emergency or as a starter dose). b. To sign for delivery receipt of oral pills in the e-kit. These deficient practices could have caused the medications contained inside of the e-kit to lose their potency (strength) and not be effective and inaccurate records of emergency pills on hand, resulting in missed doses, or lack of emergency medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food by methods that conserved flavor and appearance. This deficient practice placed 74 of 74 facility residents on regular (diet with no restrictions) and soft mechanical (chopped foods) texture diets and 19 of 19 facility residents on puree diet (blended to a smoothie like consistency) at risk of not consuming adequate calories, and carbohydrates causing unplanned weight loss, a consequence of poor food intake, getting food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light was answered in a timely manner for three (3) of eight (8) sampled residents (Resident 62, 44, and 84). This deficient practice had the potential to result in delay in meeting the residents' needs for assistance which could lead to accidents such as falls.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's clinical records were updated about advance directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) for three of six sampled residents (Residents 249, 69, and 32) by failing to maintain a current copy of the resident's advance directives in the resident's clinical record. This failure resulted in or had the potential to cause conflict with a resident's wishes regarding health care for Residents 249, 69, and 32.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to protect the privacy of personal and medical information of two of the 20 residents (Residents 91 and 300) by having residents' personal and medical information exposed prior to logging out of the computer. This deficiency violated the rights of residents to personal privacy and confidentiality of personal and medical information for Residents 91 and 300.

Inspectors wroteBased on interview and record review the facility failed to complete quarterly fall risk assessment for one of two sampled residents (Resident 16). This deficient practice caused noncompliance with assessment requirements for Resident 16.

Inspectors wroteBased on interview and record review, the facility failed to pre-admission screening and resident review Preadmission Screening and Resident Review (PASARR - Patient screening prior to admission, to determine if the person has, or is suspected of having, a mental illness, intellectual) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and effort for two of eight sampled residents (Residents 2 and 23) This deficient practice placed the residents at risk of not receiving necessary care and services they need for Residents 2 and 23.

Inspectors wroteBased on interview and record review the facility failed to update activity of daily living (ADL) care plan for one of one sampled resident, Resident (57). This deficient practice may have caused staff to be unknowledgeable about Resident 57's level of assistance for feeding subsequently causing Resident 57 to waste food with the potential of losing weight.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain safe and functional toilets for two (2) of eight (8) resident bathrooms and wheelchair armrests for Residents 2 and 66. This deficient practice had the potential to place residents and staff at risk for accidents with injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the facility's Interim Director of Nursing (IDON) had appropriate competency and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of all 96 residents in the facility. This deficeint practice had the potential to place all 96 residents at risk of an adverse outcome to a resident's care or services. Cross Reference: F644, F730, and F919.

Inspectors wroteBased on interview and record review, the facility failed to maintain documentation of state certification for three out of three sampled certified nurse aids (CNA: CNA 5, CNA 6, and CNA 7). This deficient practice had the potential to lead to inadequate care and a delay resident's care.

Inspectors wroteBased on interview and record review, the facility failed to ensure three out of three sampled certified nurse aids (CNA: CNA 5, CNA 6, and CNA 7) had annual performance evaluations and competency verifications needed to provide care and services to all 96 facility residents. This deficient practice had the potential to lead to inadequate care and a delay resident's care.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the person functioning as the social worker in the facility met the qualifications required to be employed as a full-time social worker at the facility, which had 144 licensed beds. This deficient practice had the potential for the resident's social service needs not being identified and provided.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain safe and functional toilets for two (2) of eight (8) resident bathrooms and wheelchair armrests for Residents 2 and 66. This deficient practice had the potential to place residents and staff at risk for accidents with injury.

Inspectors wroteBased on interview and record review, the facility failed to provide nutritional care and services to two of three sampled residents (Resident 1 and 2) by failing to: 1. Ensure implementation and modification of interventions consistent with Resident 1 and 2's needs and goals per registered dietitian (RD) recommendations when weekly weights were ordered for monitoring on 12/21/2023. 2. Ensure recording of weights for Residents 1 and 2 were properly documented. This deficient practice placed Resident 1 and at risk for possible weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control measure and prevention program by failing to: 1. Ensure staff N95 (filtering facepiece respirator) fit testing (test used for proper respirator fit) log record was updated. 2. Ensure one of five sampled staff (Licensed Vocational Nurse 1-LVN 1) was wearing proper fit tested N95 mask when entering a COVID-19 (Coronavirus- a deadly respiratory disease transmitted from person to person) isolation room. These deficient practices had the potential to result in the spread of disease and infection to residents and staff.

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to implement procedures to ensure safe dispensing and administration of medications from one out of four observed medication carts (medication cart 2) by failing to: 1. Ensure two marked (with name and room number of Resident5 and Resident 6) medicine cups containing pills were not left unattended on top of the unlocked medication cart 2. Inside the unlocked drawer were additional 10 marked (with name and room number of Residents 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, and 16) medicine cups stacked on top of each other with pills inside each cup. 2. Ensure the licensed nurses prepared medications immediately prior to administration and other safe preparation practices, as per facility policy and national standard of practice. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect two of three sampled residents (Resident 1 and 2) from verbal and mental abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) from Resident 3 by failing to: 1. Immediately correct and intervene in reported or identified situations in which verbal abuse, physical threats, and intimidation from Resident 3 whenever Resident 1 and Resident 2 used a bathroom shared with Resident 3. 2. Investigate allegations of ongoing bullying, verbal abuse, physical threats, and intimidation from Resident 3 to Resident 1 and Resident 2. 3. Protect Resident 1 from Resident 3 by responding to the call light when Resident 1 called for help to use the shared bathroom. [...]

Inspectors wroteBased on interview and record review the facility failed to provide emergency medical services in accordance with professional standards of practice for one out of two sampled residents (Resident 4) as indicated in the resident's code status (level of medical interventions a person wishes to have started if their heart or breathing stops), by failing to: 1. Perform Cardiopulmonary resuscitation (CPR) as indicated in Resident 4's physician order and Physician Orders for Life-Sustaining Treatment (POLST, a written medical order from a physician, nurse practitioner, or physician assistant that helps give people with serious illnesses more control over their own care by specifying the types of medical treatment they want to receive during serious illness). 2. Call 911 (designated as a universal emergency number) for emergency medical services assistance and transport to the hospital. [...]

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to access and document medication administration using a secured device to protect Resident privacy by allowing licensed nurses to use their personal laptops for documentation of medication administration. These deficient practices placed all 104 facility residents at risk for having their confidential information accessed and shared with unauthorized people and/or entities.

Inspectors wroteBased on observation, interviews, and records review, the facility failed to ensure six of eight staff, Registered Nurse 4 (RN 4), Licensed Vocational Nurses 2, 4, 11, and 14 (LVNs 2, 4, 11, and 14) and Certified Nurse Aides 9 and 10 (CNAs 9 and 10), were competent (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully) and had the skills set to perform Cardiopulmonary Resuscitation (CPR - a lifesaving emergency procedure performed when a person breathing and/or heart stops) correctly during a medical emergency. This failure had the potential for facility staff to perform ineffective CPR which could result in death for a resident found unresponsive, not breathing and pulseless (no heartbeat).

Inspectors wroteBased on interviews, and record reviews the facility failed to implement abuse policy and procedure when the facility did not report to the State Agency or law enforcement of the alleged abuse between three residents (Resident 1, 2, and 3). This deficient practice resulted in Resident 1 and Resident 2 exposed to continuous verbal and mental abuse from Resident 3 causing mental anguish and emotional distress. Cross Reference: F600, F610. F689, F645, F740 Findings a. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to investigated allegations of ongoing resident-to-resident abuse for three of three residents (Resident 1, 2, and 3). This deficient practice resulting in Resident 1 and Resident 2 continuously being abuse. Cross Reference: F600, F609, F689, F645, F740 Findings a. [...]

Inspectors wroteBased on interview and record review, the facility failed to properly conduct Preadmission Screening and Resident Review Level 1 (PASRR1- a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care), reevaluate it and notify the appropriate state mental health authority after a significant change in the resident's mental condition for one of one sampled resident (Resident 3). This deficient practice resulted in Resident 3 not receiving specialized mental health services to manage the resident's behaviors including harassing and threatening other residents and staff. Cross References:

Inspectors wroteBased on interview, and record review the facility failed to provide the care, assistance, and supervision needed to ensure an environment free of risks and hazards for one out of one sampled resident (Resident 1), by failing to provide supervision and assistance with ambulation, and respond to the resident's calls for assistance in a timely manner. These deficient practices resulted in Resident 1 falling on 11/30/2023 resulting in a lumbar (lower back) fracture. Cross Reference:

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 3) was provided necessary behavioral health care and services for the treatment of Resident 3's displays of verbal and physical aggression towards others by ensuring: 1. Ensure Resident 3 was properly assessed after displaying a significant change in mental condition. 2. Review and revise Resident 3's Behavioral health care plan after the resident displayed behavioral changes (verbal and physical). 3. Ensure facility residents and staff (general) did not experience Resident's 3's aggressive behavior, verbal and physical threats when using a shared bathroom. This deficient practice denied Resident 3 of the care and services needed to achieve the highest practicable physical, mental, and psychological wellbeing and placed. Cross Reference:

Inspectors wroteBased on observation, interviews, and record reviews, for one of three sampled residents (Resident 14), the facility failed to ensure Resident 14 received scheduled medications in accordance with physician's orders. As a result, Resident 14 did not receive scheduled medications on 2/16/2924 which placed Resident 14 at increased risk for repeat medication error, hospitalization, and/or death.

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to ensure one of four medication carts (Med Cart 2) remained locked, secured, and not left unattended per facility's policy and procedures. This deficient practice had the potential for unauthorized person to access medications in Med Cart 2, diversion of medication, and consumption of the medications by unintended person with the potential to result in undesired outcome including death.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive care plan that met the care/services based on the resident's individual assessed needs for two of six sampled residents (Resident 4 and Resident 5) by failing to: 1. Develop a comprehensive care plan for Resident 4 who was on oxygen therapy. 2. Develop a comprehensive care plan for Resident 5's an indwelling urinary catheter (foley catheter - a hollow tube left implanted in a body canal or organ, especially the bladder, to promote drainage) These deficient practices had the potential to result negative impact on residents' health and safety, as well as the quality of care and services received.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident received appropriate treatment and services to prevent urinary tract infections (UTI-an infection in any part of your urinary system your kidneys, ureters, bladder and urethra) for one of one sampled resident (Resident 5) by: 1. Failing to assess Resident 5 who had an indwelling urinary catheter (foley catheter - a hollow tube left implanted in a body canal or organ, especially the bladder, to promote drainage) and document sediments (visible particles in the urine that can be made up of a variety of substances, including sloughing of tissue (debris). The most common cause of sediment in the urine is a UTI. 2. Failing to notify the physician of sediments in Resident 5's urine. As a result, Resident 5 was placed at risk for a delay in necessary care and services to treat a possible UTI.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Provide necessary respiratory care services for one out of one sampled resident (Resident 4) by failing to ensure the nasal cannula (NC -a connector attached to oxygen) tubing and humidifier (a device used to make supplemental oxygen moist) was changed per policy. 2. Ensure a physician's order are in place for oxygen therapy. These deficient practices had the potential for the residents to develop respiratory infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control measure and prevention by failing to 1. Ensure one of one sampled facility staff, Housekeeping 1 (HS 1) wear the required personal protective equipment of an N95 respirator (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) while cleaning resident's room. 2. Ensure one of two sampled facility staffs, Licensed Vocational Nurse 2 (LVN 2) wear the required eye protection/goggles as a PPE while providing care to residents. These deficient practices had the potential to result in the spread of disease and infection to residents and staff.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care in a manner that promote or enhanced resident ' s dignity and respect for two of seven sampled residents (Residents 2 and 10) by failing to ensure facility staff introduced self-prior to entering the residents ' rooms. This deficient practice had the potential to cause psychosocial harm to the resident and can violate resident ' s right to be treated with dignity and respect.

Inspectors wroteBased on observation, interview and record review, the facility failed to meet professional standards of practice for two of two sampled residents (Residents 6 and 8) by failing to ensure physician order for wound care treatment was checked via treatment administration record (TAR) before providing wound care treatment to Residents 6 and 8. This deficient practice had the potential to negatively impact the delivery of service given to Residents 6 and 8.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident environment remains as free of accident hazards as possible and to provide adequate supervision to prevent accidents for one of one sampled resident (Resident 6) by failing to ensure Resident 6 ' s diclofenac 1 percent (%) cream (medication that reduces pain and inflammation), visine eye drops (medication that treats eye symptoms such as redness, itching and allergies) and Benadryl extra strength (ES) cream (medication that treat itchy skin, rash and pain) were left unattended in Resident 6 ' s bedside table tray. This deficient practice had the potential to compromise Resident 6 ' s safety when being administered inappropriately.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain proper storage of medications to one of one sampled resident (Resident 6). Resident 6 had diclofenac 1 percent (%) cream (medication that reduces pain and inflammation), visine eye drops (medication that treats eye symptoms such as redness, itching and allergies) and Benadryl extra strength (ES) cream (medication that treat itchy skin, rash and pain) in Resident 6 ' s bedside table tray. This deficient practice had the potential to compromise Resident 6 ' s safety when being administered inappropriately.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain accurate medical record in accordance with accepted professional standards and practices for two of two sampled residents (Resident 6 and 8) by failing to ensure accurate documentation of wound care treatment in Resident 6 and 8 ' s treatment administration records (TARs) when Treatment Nurse (TN) documented wound care treatment first before providing care to Residents 6 and 8. This deficient practice had the potential to negatively impact the delivery of service given to Residents 6 and 8.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control measure and prevention to one of one sampled resident (Resident 6) by failing to ensure handwashing was completed and changing the gloves after removing an old wound dressing to Resident 6. This deficient practice had the potential to result in the spread of an infection and inability to promote wound healing.

Inspectors wroteBased on interview and record review, the facility failed to implement their Personnel Records policy by failing maintain the personnel file which included a background check for Janitor (JT) 1. This deficient practice had the potential to place the residents at the facility at risk for elder abuse.

Inspectors wroteBased on observation and interview, the facility failed to provide a functioning call light (the primary method of patient-nurse communication in a hospital setting, often used as a measure of nurse responsiveness) for three of five sampled residents (Residents 1, 2, and 3). This deficient practice had the potential to result in staff delay in meeting resident's needs for hydration, toileting, and activities of daily living as well as a delay in provision of assistance which may lead to falls and accidents.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sample residents (Resident 1) a care plan developed for enterocutaneous fistulae care upon admission and revised as indicated in the facilities policy and procedures. This failure had the potential to negatively affect the delivery of care and services for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sample residents (Resident 1): 1. had and initial care plan developed for nephrostomy tubes and revised which each incident of dislodgement. 2. had Interdisciplinary team meetings completed in a timely manner after nephrostomy tube dislodgement. 3. had staff in-service trainings initiated and completed for all nursing staff for nephrostomy tube care. 4. had an accurate assessment documented in the medical record detailing site of nephrostomy tube dislodgement for two of five instances. This failure resulted in five instances where Resident 1 ' s nephrostomy tubes were dislodged and required hospitalization to replace the dislodged tubes.

Inspectors wroteBased on interviews and record review the facility failed to have a system in place to ensure facility staff providing care to residents were licensed, certified, or registered as per state laws and facility policy. An unknown person worked in the facility using Certified Nursing Assistant 1 (CNA 1) ' s identification and provided care to residents from June 2023 to August 2023 with no valid certification that was verified by the facility. This deficient practice placed all residents assigned to CNA 1 at risk for serious injury or harm from receiving unqualified incompetent care.