Skyline Healthcare Center - San Jose

Inspectors wroteBased on interview and record review, the facility failed to prevent abuse for one of three residents (Resident 1) when Licensed Vocational Nurse A (LVN A) hit and punched Resident 1's wound with his fist. This failure resulted in pain to Resident 1 and affected the resident's psychosocial well-being.

Inspectors wrote3. During an observation and concurrent interview with nurse supervisor H (NS H) on 6/23/25, at 8:55 a.m., one of the facility's medication rooms was inspected. There was a refrigerator inside this medication room, which was designated to store the residents' food. There was one pitcher of pinkish-red fluid and one unopened container of applesauce in this refrigerator. The thermometer inside this refrigerator had a temperature reading of 60 degrees Fahrenheit (F, unit of temperature measurement). NS H confirmed this observation and confirmed the temperature of the food refrigerator should be maintained between 35 and 41 degrees F. During a follow-up observation and concurrent interview with NS H on 6/23/25, at 9:03 a.m., the thermometer inside the refrigerator was checked again. At this time, the refrigerator door had been closed for eight minutes. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that garbage was stored properly when two out of four outside dumpsters were overfilled of garbage, with their lids, not fully closed and plastic bags with trash were not placed in the covered dumpsters. These failures had the potential to attract insects, rodents, and other pests to the facility that could affect the two hundred thirty-eight residents residing in the facility.

Inspectors wrote4. During an observation on 6/25/25, at 1:41 p.m., certified nursing assistant C (CNA C) was feeding lunch to Resident 163, who was lying in bed with the head of the bed slightly elevated. CNA C was standing over Resident 163 while feeding her. During an observation and concurrent interview with nurse supervisor D (NS D) on 6/25/25, at 1:41 p.m., NS D confirmed the above observation and stated CNA C should sit at eye level while feeding the resident. During an interview with the director of staff development (DSD) on 6/27/25, at 8:16 a.m., the DSD explained staff should sit at eye level while feeding the residents in order to maintain the residents' comfort and dignity. The facility's undated policy titled Assisting the Resident to Eat indicated, Sit at eye level in front of the resident. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the residents would know and be reminded of the results of the previous state recertification surveys when 5 out of 14 residents who attended the Resident Council meeting, (Residents 5, 33, 52, 80, and 106), did not know about the results of the previous state recertification surveys or where the binder containing the survey results was located. These failures jeopardized the right of the residents to know and examine the results of the previous state recertification surveys and the plan of corrections that the facility did for those failures.

Inspectors wrote2. During the observation of Resident 7 on 6/23/25 at 12:43 p.m., Resident 7 was alert, calm, comfortable, verbally responsive and able to answer questions. Review of Resident 7's face sheet indicated, Resident 7 was readmitted to the facility on [DATE] with the primary diagnosis of unspecified paraplegia (a condition characterized by the paralysis of the lower half of the body, typically including the legs and sometimes the torso or the trunk of the human body). Review of Resident 7's physician order report from 5/24/25 to 6/24/25 indicated, Resident 7 had an order to monitor weekly weights every Saturday, at 9:00 a.m., once a day, ordered on 4/6/25. Review of Resident 7's weight records indicated that Resident 7's weights were checked on the following dates: a. 5/20/25 - 190 pounds (lbs, unit used to measure the mass); b. 5/7/25 - 195 lbs; c. 4/22/25 - 195 lbs; d. 3/19/25 - 182 lbs; e. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate accountability of controlled medication (medication with high potential for abuse and addiction) when random controlled medication use audit for seven of 12 residents (Resident 347, 28, 174, 67, 38, 65, and 226) did not reconcile when: 1. The medication was documented on the Medication Administration Record (MAR, used to document medications taken by each individual) to indicate they were administered to Residents 65, 38, and 28 but was not signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications.), and 2. The medication was signed out of the CDR but not documented on the MAR for Residents 347, 67, 174, 65, and 226. These failures resulted in inaccurate accountability and had the potential for misuse or diversion of controlled medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored in accordance with facility policies when: 1. In one of six medication rooms, the were medications with different routes of administration stored in the same bin. There were also active and discontinued medications stored in this bin; 2. One opened bottle of 1,000 milliliters (ml, a unit of measurement for volume) 0.9% sodium chloride solution (known as normal saline- a common medical solution containing 0.9 grams of sodium chloride per 100 milliliters of water. It is an isotonic solution, meaning it has the same concentration of solutes as the blood and body fluids (NS) and small bottle of 0.9% (NS) was stored at Resident 65's bedside table unattended. and 3. One bottle of used 100 ml NS was stored at Resident 205's bedside table unattended. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. Resident 345's used and opened urinal was next to the spirometer (an apparatus for measuring the volume of air inspired and expired by the lungs- measures ventilation, the movement of air into and out of the lungs) on top of the bedside table; 1a. Resident 46's yankauer suction tube (oral suctioning tool) that was attached to suction machine was stored inside of the open clean gloves box on top of the bedside table; 1b. Resident 9's suction machine and nebulizer machine (device used to deliver medication in the form of a mist for inhalation) were covered by a used wash basin at the bedside table; 1c. Resident 128's used urinal without covering was on top of the bedside table ; 1d. Resident 330's soiled linens were on the floor; 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a safe and sanitary environment when the floors in the dishwashing area of the kitchen were very wet and there was no safety sign in the area. These failures could affect the health and safety of kitchen staffs and individuals that might go inside the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to maintain an effective infection control training program for laundry staff regarding routine cleaning of dryer lint. The facility's documentation indicated laundry staff did not clean the dryer lint for several hours on multiple days. This failure had the potential to compromise the health and safety of the residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the call light button (a cord with a button used by the resident to request assistance) for one of 238 residents (Resident 25) was within reach and appropriate for her condition. This failure had the potential to result in delays of care and treatment.

Inspectors wroteBased on interview and record review, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN, a notice that transfers potential financial liability when a resident comes off Medicare Part A) for two of three residents (Residents 95 and 186). This failure had the potential to compromise the residents' right to appeal (apply for reversal of) the facility's decision to discontinue Medicare Part A services (skilled treatments paid for by Medicare). This failure also had the potential to result in the residents or residents' representatives not being informed of their payment responsibilities to the facility after Medicare Part A services ended.

Inspectors wroteBased on interview and record review, the facility failed to complete an annual Minimum Data Set (MDS, an assessment tool) for one of three residents (Resident 89). This failure had the potential to compromise the facility's ability to develop and implement care plan interventions.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete the Minimum Data Set (MDS, an assessment tool) for two of 36 sampled residents (Residents 164 and 192) when: 1. For Resident 164, multiple falls were not coded on the MDS; and 2. For Resident 192, tobacco use was not coded on the MDS. Failure to accurately complete the MDS had the potential to compromise the facility's ability to develop and implement care plan interventions.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident-centered baseline care plans were developed within 48 hours of admission for two of thirty-six sampled residents, (Residents 337 and 380), when: 1. For Resident 337, there was no communication problem care plan that was initiated and 2. For Resident 380, there was no baseline activity care plan that was created, and she had no activity care plan at all. These deficient practices had the potential to cause delays in the continuity of care and communication which could negatively affect residents' health, safety and delivery of care.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to revise the comprehensive care plans to address the individual care needs for two of thirty-six sampled residents, (Residents 202 and 18), when: 1. Resident 202's care plan interventions were not revised or modified related to falls and cognitive function. 2. Resident 18's care plan for antibiotic, not resolved. This failure placed the residents at risk of not being provided appropriate, consistent, individualized care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the proper use of side or bed rails (adjustable rigid bars attached to the side of a bed) for one (Resident 380), of six residents who used side rails that were investigated, when Resident 380 did not have a physician's order for her use of side rails. This failure caused the resident, to not have the proper approval from the physician for her use of side rails which could jeopardize the resident's safety.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure two of 36 sampled residents (Residents 106 and 195) received their lunch in accordance with scheduled meal times. This failure had the potential to result in reduced food palatability (quality of taste), which could negatively affect the residents' meal intake and nutritional status.

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician orders of one of three residents (Resident 1) were followed when a nurse did not perform a blood sugar check, administer insulin, and administer the correct dose of medication to Resident 1 timely. These failures had the potential to affect the health of Resident 1.

Inspectors wroteBased on observation, interview and record review, the facility failed to store medications in a safe manner when nursing staff left medications unattended on the bedside table in a resident room. This failure had the potential to allow residents and unauthorized staff to access medications.

Inspectors wroteBased on interview and record review, the facility failed to provide the necessary behavioral health service to maintain the highest practicable mental and psychosocial well-being in accordance with the comprehensive assessment to two of three sampled residents (1 and 2) when their psychiatric services were not being followed up. This failure had a potential to affect maintaining Resident 1 and 2's highest practicable mental and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their plan of correction from 2024's recertification survey to have immediate pest treatment to maintain an effective pest control program for ensuring facility is free of pests and rodents when pest sightings were identified, and cockroaches were seen ongoing by staff and residents in the facility. This failure affected residents' quality of life to live in a health and sanitary environment.

Inspectors wroteBased on observation and interview, the facility failed to ensure refuse (any disposable materials, which include recyclable and non-recyclable materials) was disposed of properly when the lid of the garbage disposal bin in the kitchen was not placed. This failure had the potential to attract insects, rodents, and other pests to the facility and could affect the 238 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the environment was free of pests, as evidenced by multiple flying insects seen in the resident's room and the hallway. This failure had the potential to cause a health hazard to the 238 residents residing in the facility.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that residents received the treatment and care in accordance with professional standards of practice related to pain management for one out of three sampled residents (Resident 1) when 1. The licensed nurses did not follow physician's order to administer the pain medications as needed (PRN) based on the pain assessment documented; 2. The licensed nurses did not update Resident 1's care plan for pain management; 3. The licensed nurses did not follow the physician's order to administer the PRN medication for severe pain; and 4. The pain scale did not include the pain levels 1, 3, 5, and 7. These failures had the potential for Resident 1's pain not being properly managed and could negatively affect Resident 1's comfort and well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a sanitary environment and safe food handling practices were maintained within the food service operation for 240 of 244 residents, which led to a cockroach infestation at the facility. This was evidenced by: 1. a) Live and dead cockroaches found in the kitchen under the meal tray line station and in food cooking preparation areas, confirmed by dietary staff, who reported the kitchen had a cockroach problem; Walls in the kitchen had uncovered holes with peeling baseboards, shelves had openings, and there were multiple broken kitchen appliances, which prevented adequate cleaning and sanitizing, and harbored pests; b) One of two ice machines managed by the Dietary Department had a dead baby cockroach inside on the ice curtain that covers the ice making grid water trough; [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure the Food and Nutrition Services Department, the kitchen, and resident rooms were free from cockroaches, with an effective pest control program maintained. This failure caused 244 residents to be exposed to potential food contaminants that could cause food-borne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins).

Inspectors wroteBased on observation, interview, and record review, the facility failed to offer and/or attempt alternatives prior to the use of side rails (or bed rails, adjustable rigid bars attached to the side of a bed [examples include safety rails, grab bars, and assist bars]) for 38 of 39 sampled residents (Residents 65, 642, 221, 21, 33, 86, 226, 68, 120, 64, 89, 16, 182, 58, 41, 50, 31, 208, 22, 210, 83, 213, 132, 127, 443, 168, 82, 145, 160, 56, 139, 128, 792, 184, 692, 201, 229, and 192). The survey team expanded the sample and identified that a total of 230 residents had side rails. The facility failed to ensure proper use of side rails when: 1. There was no documentation that indicated alternatives were offered and/or attempted prior to the use of side rails for 230 of 230 residents with siderails; 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the food service staff had appropriate competencies to carry out the food service safely and effectively functions when: 1. A kitchen staff member did not demonstrate the correct technique for testing the sanitation level on the dish machine. 2. A kitchen staff member did not demonstrate thermometer calibration correctly. 3. A kitchen staff member did not demonstrate the correct techniques for testing the sanitizer in the red buckets. This failure in staff competency had the potential to result in improperly sanitized resident dishes and food contact surfaces and expose residents to food-borne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins). Cross reference 812 and CCR-72345(a)

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure the facility approved menus were followed as printed. This failure altered the availability of foods served to residents, which could decrease food intake and compromise the nutritional status 240 of 244 medically vulnerable residents who consumed food from the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow its policy related to resident food brought in from outside the facility which facilitated improper food storage not safe for resident consumption. This failure had the potential to expose 240 of 244 residents who consumed food orally to harmful bacteria that could result in food borne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a comfortable and safe water temperature level for residents in Station 6 hallway. This failure had the potential for 11 residents to have an uncomfortable water temperature.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an environment free of accident hazards for three of 39 sampled residents (Residents 143, 145 and 208) when: 1. Resident 143 was smoking in his room 2. For Resident 145, cigarettes and smoking materials were at the bedside 3. Resident 208's wander guard (small device placed on the ankle or wrist of a resident, alarms to notify the staff if a resident tries to leave the facility) functionality was not tested. These failures placed the residents at risk for accidents and subsequent harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. Housekeeper did not change gloves in between rooms and did not perform hand hygiene after removal of gloves; 2. Resident 22's nasal cannula was not stored properly when not in use; 3. Restorative Nursing Assistant did not perform hand hygiene while serving and setting up lunch trays in between residents; 4. Licensed Vocational Nurse N (LVN N) did not wear the proper personal protective equipment (PPE, equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) while inside the enhanced droplet precaution (used to prevent the spread of pathogens [an organism causing disease to its host] that are passed through respiratory secretions) room; 5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three ice machines, a nourishment reach-in refrigerator, walk-in freezer's fans, a walk-in refrigerator, and two reach-in refrigerators, were maintained in a safe, operating, and fully functioning manner, according to the manufacturer's guidelines and standards of practice. This failure had the potential to expose 244 residents to food contaminants that could cause food-borne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins).

Inspectors wroteBased on observation, interview and record review, the facility failed to provide at least 80 square feet per resident in multiple resident bedrooms. This failure could affect the residents' safety and impede provision of care to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment when there was water leaking from the ceiling in multiple areas inside the facility due to rain. This failure had the potential to compromise the health and safety of the residents, staff, and visitors in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their policies on self-administration of medication (resident takes medication without staff assistance) when there were no assessments performed for self-administration of medications, and medications were left at the bedside for 3 of 35 sampled residents (33, 58, and 90). These failures had the potential for unsafe and improper administration of medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident's needs were accommodated for one of 39 sampled residents (Resident 544) when Resident 544's call button (a red button used by residetns to request assistance) was not within reach to use. This failure had the potential to affect residents' physical and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the confidentiality of personal and medical records of one resident (Resident 116) when a Resident Face Sheet (a document that contains personal and medical information) was left on top of an unattended medication cart. This failure had the potential to put a resident at risk for identity theft, insurance fraud and discrimination.

Inspectors wroteBased on interview on record review, the facility failed to accurately code the minimum data set (MDS, an assessment tool) assessment, Section N - Medications for one of 39 sampled residents (Resident 213). This failure resulted in Resident 213's inaccurate MDS.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of 39 sampled residents (Resident 221 and 82) completed a Level II Mental Health Evaluation as part of the pre-admission screening and resident review (PASRR, a federal requirement to help ensure that individuals who have mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care). These failures had the potential for inaccurate care and services provided to residents with a mental disorder, intellectual disability or related conditions.

Inspectors wroteBased on interview and record review, the facility failed to ensure a pre-admission screening and resident review (PASRR, a federal requirement to help ensure that individuals who have mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) was completed for two of 39 sampled residents (Residents 127 and 132). These failures had the potential for inaccurate care and services provided to residents with a mental disorder, intellectual disability or related conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a care plan for two of 39 sampled residents (Resident 83 and 135) when: 1. Resident 83's language barrier care plan was not initiated and the communication binder (it is a compilation of photos, symbols, or illustrations to help people with limited language skills express themselves) was not available for Resident 83 and staff's use; and 2. Resident 135's care plan was not implemented. These failures had the potential for inaccurate development and implementation of personalized and resident-centered care plans that would address the residents' identified concerns and needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper foot care was provided to one of 39 sampled residents (Resident 221) when Resident 221's long, jagged (has a rough, uneven shape) toenails were not trimmed by either licensed nurses or podiatrist (medical specialists who help with problems that affect your feet or lower legs). This failure had the potential to increase the risk for the development of foot ulcer and infection.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure a resident, (Resident 210) with an unintended, unplanned severe weight loss of 12.69% in six months had acceptable parameters of nutritional status was monitored from (5/4/23-10/18/23) according to facility policy and standards of practice when: 1) The facility did not reassess the resident's nutritional status, obtain regular laboratory values, or modify the interventions after severe percent of weight loss occurred, according to facility policy and standards of practice. 2) Weekly weights to monitor Resident 210's weight status after a loss of five or ten percent of body weight was not available or provided, according to policy. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that proper care and treatment services for oxygen (O2) was provided for one of two sampled residents (Resident 22) when Resident 22's physician order for oxygen administration was not followed. This failure had the potential to result in complications related to improper treatment while receiving O2 therapy.

Inspectors wroteBased interview and record review, the facility failed to ensure accurate accountability of controlled medications (those with high potential for abuse or addiction) when random controlled medication use audits did not reconcile for one out of six (6) randomly checked (Resident 168) residents. The medication was signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but not documented on the Medication Administration Record (MAR) to indicate they were given to the resident. There were two controlled medications unaccounted for. This failure had the potential for misuse or abuse of controlled medications.

Inspectors wroteBased on observation, interview, and record review, the facility had a medication error rate of 10.71% when three (3) medication errors occurred out of 28 opportunities during the medication administration for one out of four residents (Resident 190). The failure resulted in medications not given according to the physician's orders and had the potential for Resident 190 not receiving the full therapeutic effects of medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respect and dignity was maintained for 4 of 35 sampled residents (Resident 50, 58, 226, and 229) and one non-sampled resident (Resident 67) when: 1. For Residents 50, 67, and 226, staff provided feeding assistance while standing; 2. Staff failed to provide a privacy bag for Resident 58's urinary drainage device; 3. Staff referred to Resident 229 as a feeder. These failures had the potential to affect the emotional and psychosocial well-being of the residents.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, admission to the Facility, for one of 39 sampled residents (Resident 208), when Resident 208 was admitted to the facility without a physician's order to certify admission. This failure had the potential to affect Resident 208's care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from verbal and physical abuse for two of three residents (Residents 1 and 2) when: 1. Resident 1 sustained facial injuries when Resident 2 scratched her in the face and was transferred to the emergency room (ER). 2. Resident 2 sustained emotional distress by feeling upset when Resident 1 said bad words, and complained of pain on her breast when Resident 1 grabbed her breast. This failure had caused both emotional and physical harm to Residents 1 and 2.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was treated with respect and dignity when the certified nursing assistant A (CNA A) pulled the standing Resident 1 backward and did not ask for assistance in putting the Resident 1 in bed. This failure resulted in not ensuring Resident 1 ' s right to be treated with respect and dignity and could potentially result in low-self-esteem and self-worth.

Inspectors wroteBased on interview and record review, the facility failed to provide supervision to prevent 1 out of 10 residents (Resident 1) who was at risk for elopement from leaving the facility when Resident 1 went out to smoke outside the facility and did not return the same day. These failures compromised Resident 1's health and safety, as she was found by police officers and was admitted to the acute hospital for treatment and evaluation the next day 12/24/2022

Inspectors wroteBased on interview and record review, the facility failed to ensure the doctor or nurse practitioner (NP)/or physician assistant (PA) was promptly promptly informed of any condition change/s for one of three sampled residents (1) when after Resident 1's fall incident on 10/31/23, she complained of severe pain (10 out of 10 ) during morning shift on 11/4/23, and on the next day 11/5/23, she developed bruise (injury appearing as an area of discolored skin on the body, caused by a blow or impact due to rupture of underlying blood vessels.) on her right hip and the vagina area. This failure could jeopardize Resident 1 ' s health and safety due to the delay in Resident 1 receiving appropriate treatment /interventions that included timely transfer to acute hospital for further management and evaluation.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the timeliness of the radiology services for one of three sampled residents (Resident 1) when the physician ' s order to do a stat (immediately) x-ray (a photographic or digital image of the internal composition of a part of the body) of right hip to rule out fracture was done as ordered. This failure had delayed meeting Resident 1's needed care and treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure the staff report one of two incidents of a resident-to-resident altercations when certified nursing assistant A (CNA A) reported to the licensed nurse about the altercation between Resident 1 and Resident 2, but the incident was not reported until four days later, when Resident 1 informed the staff about it. This failure had the potential to put the residents at risk for further abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide personal hygiene to one of three sampled residents (1) when her adult diapers were not changed as per plan of care and task schedule to keep clean and dry after each incontinent episodes. This failure had the potential risk for developing complications such as skin rash or urinary tract infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure the facility was free of pests and rodents when cockroaches were seen by three of three sampled residents (1, 2 and 3) and 16 randomly selected residents ( (4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17,18, 19)in the facility. This failure affected the residents' quality life, and dperived them to live in a healthy and sanitary environment.

Inspectors wroteBased on interview and record review, the facility failed to provide a copy of resident's medical record upon verbal request for one of three sampled residents (1) when her responsible party (RP, is a person who has been chosen to act or make decisions on behalf of another person) made a verbal request for Resident 1's medical records over months and did not receive any response from the facility. This failure had a potential to limit resident's rights for accessing records.

Inspectors wroteBased on interview and record review, the facility failed submit an investigation summary within 5 working days to the California Department of Public Health (CDPH, state survey agency) regarding an alleged physical abuse incident that occurred between a certified nursing assistant A (CNA A) and one of two sampled residents (Resident 1). This failure had the potential to delay the facility's recommendation for action to ensure the safety for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to notify the conservator (a responsible adult who manages the daily life and/or finances of an adult, who is unable to adequately care for themselves because of a cognitive or physical disability) for one of three residents (Resident 1) when there was an incident that Resident 1 reported Resident 2 punched her underneath the left side of her breast and Resident 2's conservator was not notified of the incident. This failure resulted in Resident 2's conservator not being informed of the incident and any possible change in Resident 2's condition.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide supervision to prevent one of 14 residents (Resident 27) who were at risk for elopement from leaving the facility without staff's knowledge and permission when: 1. Staff did not provide Resident 27 with supervision and one staff physical assistance for locomotion on unit (how resident moves between locations in her room and adjacent corridor in the same floor), and locomotion off unit (how resident moves to and returns from off-unit locations [i.e., hallways, dining, or how resident moves to and from distant areas on the floor]). 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accurate accountability of controlled medications (those with high potential for abuse or addiction); and safe and effective use and administration of medications when: 1. Random controlled medication use audits 9 out of 9 residents (Residents 11, 18, 23, 37, 116, 118, 133, 139, and 163) did not reconcile. The medications were signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but not documented on the Medication Administration Record (MAR) to indicate they were given to the residents. There was a total of 47 controlled medications unaccounted for. This failure had the potential for misuse or abuse of controlled medications; 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served under sanitary conditions when: 1. Four wire rack shelves had yellowish to golden brown color; 2. Two spatulas had cracked/chipped; 3. Grater (used to shred cheese and other soft food) had yellowish substance; 4. The quaternary bucket was stored near juice boxes/juice machine; 5. Two of four ice machines had black particles; 6. Scoop was inside the ice cooler; 7. Kitchen staff did not demonstrate the proper procedure for testing the strength of sanitizer used for sanitizing food contact surfaces; 8. Unit Storage's had unlabeled food and refrigerators with high temperatures. These failures had the potential to cause foodborne illness (illness resulting from contaminated food) for 223 of 232 residents who received food from the kitchen.

Inspectors wrote6a. During a medication pass observation with LVN Q on 7/12/22 at 8:09 a.m., she was observed preparing 7 medications, including 5 solid tablets, for Resident 68. During this process, LVN Q put on a pair of gloves, took out the keys from her shirt pocket to open the medication cart, then removed 2 medication blister packs/cards (a pharmacy-prepared paperboard with medications in individual doses that can be punched out of the card when administered) from the medication cart. She removed the medication tablet from each blister card by punching the blister bubble with her right thumb, and placing her left gloved hand underneath the medication card to catch the pill. Then she placed it in a small medication cup. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 7 of 35 residents (36, 26, 27, 58, 155, 234, and 95) received the necessary care, services, and correct diets when: 1. Resident 36 did not receive the assessment and treatment for her wound timely; 2. The fingernails of Resident 26, Resident 27, Resident 58, and Resident 155 were long, dirty and were not trimmed; 3. Resident 234's request for a diet changed was not addressed promptly; 4. Resident 95 had long yellowish finger nails; and 5. Licensed Nurse (LN) did not check food trays for correct diets before serving the residents in two of 6 stations (Station UVW and Station XYZ). These failures had the potential to affect the residents' care, health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure appropriate treatment and services were provided for five of seven residents (Resident 125, 228, 234, 77 and 2) when the restorative nursing assistant (RNA, program that helps residents to gain an improved quality of life by increasing their level of strength and mobility) program was not implemented. This deficient practice had the potential to result in residents' decline in range of motion.

Inspectors wroteBased on observation, interview, and record review, the facility had a medication error rate of 18.75% when six (6) medication errors occurred out of 32 opportunities during the medication administration for five out of nine residents (Resident 68, 96, 115, 152, and 195). The failure resulted in medications not given according to the physician's orders, and had the potential for residents not receiving the full therapeutic effects of medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper medication storage and labeling of medications when: 1. Nine (9) insulin (medication to lower blood sugar) pens did not have patient-specific labeling on each pen to prevent mix-up errors; 2. Temperature (temp) monitoring was missing and/or not consistently documented twice daily on the temp log sheets for two of three observed medication refrigerators; 3. Expired or discontinued medications were not put away to prevent medication errors; 4. An eye drop medication was not kept in the refrigerator until opened; and 5. A heparin (an injectable medication to prevent blood clot) vial was not dated with an open date. The deficient practices had a potential for residents to receive medications with unsafe and reduced potency from being used past their discard date; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food that conserved nutritive value and flavor when pureed food was prepared hours before serving. This failure had the potential for 50 out 232 residents who received pureed diet with reduced nutrients or flavor.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain essential equipment in good and safe operating condition when: 1. Two out of two walk-in freezers had icicle build-up; 2. Two out of five-unit refrigerators had broken parts. These failures had the potential to cause the freezers and refrigerators to be ineffective for keeping food frozen and refrigerated for 223 residents who received food from the kitchen out of 232 residents.

Inspectors wroteBased on observation interview, and record review, the facility failed to provide a safe and comfortable environment for residents and visitors when: 1. A housekeeping cart with cleaning chemicals was left unattended on the resident hallway; 2. A resident's room (Resident 2) had damaged walls and a hole in the wall. This had the potential to adversely affect the health and safety of residents and any visitors.

Inspectors wroteBased on interview and record review the facility failed to ensure for two of seven sampled residents (Resident 110 and Resident 175) advance directive instructions were clear. This had the potential for staff to not honor the wishes of the resident in the event of an emergency.

Inspectors wroteBased on interview and record review, the facility failed to conduct a comprehensive, Minimum Data Set (MDS, a standardized assessment tool) for one of 35 sampled residents (Resident 27), within 14 days of a significant change in the resident's condition. This failure had the potential for inadequate information to be gathered for the timely development of an appropriate plan of care, and the required modification of appropriate care and services for Resident 27.

Inspectors wroteBased on interview and record review, the facility failed to submit the PASRR (Preadmission Screening and Resident Review, a federally required document to ensure residents are appropriately placed) when one of five sampled residents (Resident 110), received mental illness diagnoses and did not receive a level two screening to ensure they received the services needed. The deficient practice could potentially result in Resident 110 not receiving specialized care and services appropriate for her condition.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement care plans for four of 32 sampled residents when: 1. Resident 41's Fall Risk Evaluation was not completed and Fall risk care plan was not developed. 2. Resident 117's smoking assessment was not accurately completed and smoking care plan was not developed; and fall care plan was not implemented. 3. Resident 535's smoking reassessment and care plan were not developed when he started to smoke in the facility. 4. Resident 149's fall care plan was not updated and implemented. These failures had the potential for inaccurate development and implementation of a personalized and resident-centered care plans that would address the residents' identified concerns and needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the necessary care and services to ensure prevention of development or worsening of an existing pressure ulcer (injury to the skin and underlying tissue) for one out of three sampled residents (Resident 116) observed for pressure ulcers when: 1. There was no treatment for a pressure ulcer on the sacral area (portion of spine between lower back and tailbone) that was identified on admission; 2. There was no staging of the pressure ulcer on the sacral area on admission; 3. When the physician prescribed treatment, there was no documentation that treatment orders were followed consistently; 4. There was no consistent skin assessment of the pressure ulcer; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper foot care was provided to three of five sampled residents (Resident 2, 117 and Resident 155 ) when: 1. Resident 117's long, thick toenails were not trimmed by podiatrist (medical specialists who help with problems that affect your feet or lower legs) ; 2. Resident 155's long, thick and curled toenails were not cut and trimmed by podiatrist; 3. Resident 2's long, thick toenails were not cut or trimmed by podiatrist. These failures had the potential to increase the risk for the development of foot ulcer and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care according to professional standards of practice and facility policy and procedures for two of 32 sampled residents (Residents 46 and 68) when: 1. Certified nurse assistant (CNA) and restorative nurse assistant (RNA) controlled the enteral feeding pump (a device used to deliver nutrition to the stomach using a tube); 2. Medications and feeding formula given via the gastrotomy tube (G-tube, a tube inserted through the abdomen that delivers nutrition and medications directly to the stomach) was not appropriately done for Resident 68. These failures had the potential for complications related to the enteral feeding and to cause harm to the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that proper care and treatment services for oxygen (O2) were provided for two of five sampled residents (Resident 53 and Resident 32) when: 1. Physician orders for oxygen administration for Resident 53 were not followed; 2. Resident 32's nasal cannula (NC, a device used to deliver oxygen) was not connected to the oxygen concentrator (a medical device that gives extra oxygen). These deficient practices had the potential for the residents to have complications related to improper treatment while receiving O2 therapy.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate pain management based on professional standards to one of five residents (Resident 234) when: 1. Licensed nurse did not notify the attending physician to get an order for PRN (as needed) medication for breakthrough pain (a flare of pain that might happen even though you are taking pain medicine regularly for chronic pain) 2. Licensed nurse did not follow the care plan to call MD (doctor of medicine) when pain relief measures failed to provide adequate relief. 3. Licensed nurse did not assess resident's pain when needed and did not document the pain medication when given. These deficient practices had the potential to effectively manage pain to help the resident attain or maintain the highest practicable level of well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure three of 12 residents (27, 56, and 206) were free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behaviors) when: 1. Resident 56 received Zoloft (used to treat persistent feeling of sadness, loss of interest, and panic attacks) without attempts of gradual dose reductions (GDR, a tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) since 7/3/21; 2. Resident 206 received olanzapine (used to treat extreme mood swings that include emotional highs and lows) without attempts of GDR since 8/7/21; and 3. Resident 27 received trazodone (an antidepressant medication) without monitoring for the effectiveness by monitoring number of hours of sleep. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Resident 195 was free of a significant medication error when he received citalopram (a medication for depression) twice the ordered dose. This failure resulted in the medication not given as ordered by the physician, and had the potential for increased risk of side effects (such as fatigue, dizziness, insomnia, etc.) for the resident.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide at least 80 square feet per resident in multiple resident bedrooms. This failure could affect the residents' safety and impede provision of care to the residents.