Socal Post-Acute Care

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the garbage disposal area was free of clutter by leaving the dumpster surrounded by used cardboard boxes and empty plastic containers. This failure had the potential to attract pests such as rats, cockroaches, flies, and ants, which may spread disease to the residents of the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the facility's infection control policy and procedure by failing to: 1. Ensure the two pillows were not place on the handwashing sink and ensure Family Member (FM) for Resident 64 who was on contact precaution (infection control measures used to prevent the spread of infections transmitted through direct or indirect contact) wore appropriate personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) when in contact with the resident. 2. Ensure Certified Nursing Assistant (CNA 4) performed hand hygiene (the act of cleaning your hands to remove germs, dirt, and viruses) when feeding. 3. Ensure two Certified Nursing Assistants (CNA 1 and 2) performed hand hygiene when entering and exiting the residents' rooms. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the interdisciplinary team (IDT - a coordinated group of experts from several different fields who work together) assessed one of six sampled residents (Resident 16) to determine the resident's ability to self-administer medication and keep the medications at the bedside. In addition, Resident 16 had no physician's order to self-administer medications and keep artificial tears ophthalmic solution (eye drops) and Tums tablets (chewable antacid tablets containing calcium carbonate for fast relief of heartburn, sour stomach, acid indigestion, and upset stomach) at the bedside. This deficient practice had the potential to result in unsafe medication administration and overdose of medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedure titled Answering the Call Light for one out of one sampled residents (Resident 8) with call light that was not within reach. This deficient practice placed the residents at risk of not having their needs meet timely, especially during an emergency or accident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policies and procedures regarding the formulation of an Advance Directive (AD a legal document that specify the person's medical treatment preferences and appoint a surrogate decision-maker if you become unable to communicate their wishes) for two out of four sampled residents (Resident 39 and Resident 47). As a result of this deficient practice, the facility had the potential to not honor the residents' wishes and choices in the event that they become incapable of making decisions regarding their care.

Inspectors wroteBased on observation, interview and record review the facility failed to reflect the resident's status on the Minimum Data Set (MDS - a resident assessment tool) reflected of the resident's status at the time of the assessment on two of six sampled residents (Resident 22 and Resident 42) by failing to: 1. Ensure Resident 22 fall on 1/3/2026 was documented in the MDS and Activities of daily living (ADL's) were accurately assessed and documented in the MDS. 2. Ensure Resident 42 ADL's were accurately assessed and documented in the MDS. These failures had the potential of not identifying Resident 22 and Resident 42's relevant care needs and developing a plan of care that will meet their needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled resident (Resident 10)'s care plan was updated to reflect the discontinuation of Ativan (a medication used to quickly calm the brain and nervous system). This failure had the potential to result in Resident 10 not to receive the necessary care and behavioral monitoring when Ativan was discontinued.

Inspectors wroteBased on observation, interview and record review the facility failed to assess and monitor and evaluate one of six sampled residents (Resident 16) who complained of diarrhea on and off for two months. This deficient practice had the potential to result in weight loss, fluid and electrolytes deficit.

Inspectors wroteBased on observation, record review, and interview, the facility failed to complete Restorative Nursing Assistant (RNA) treatments per physician's orders for one of six sampled residents (Resident 46) by failing to provide range of motion exercises to the affected joints. This deficient practice had the potential to promote the development of contractures (a condition involving shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of the joints) in Resident 46's upper and lower extremities.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedure for the infusion of intravenous (IV, directly into the vein) medications for one out of one resident (Resident 39) who was receiving IV medications at the facility when Resident 39's IV medication bag did not contain the appropriate labeling. This deficient practice placed Resident 39 at risk of developing IV-related complications such as infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician ordered parameters for required monitoring prior to medication administration for one of six sampled residents (Resident 63). During a medication pass, Licensed Vocational Nurse (LVN) 1 was observed preparing and about to administer Resident 63's ordered Doxazosin Mesylate (a medication used to lower blood pressure) via the gastrostomy tube (G tube). The surveyor stopped the administration when LVN 1 did not check Resident 63's blood pressure and heart rate as required by the physician's order. The order directed staff to hold the medication if the systolic blood pressure (SBP) was less than 110 or if the heart rate (HR) was below 60. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled resident (Resident 10)'s psychotherapeutic drug (medications that affects mood and behavior) Informed Consent Form (a written document ensuring voluntary participation in research or medical procedures, detailing the study's purpose, duration, procedures, risks, and benefits) was completed. This failure had the potential to result in Resident 10 or the responsible party to receive information such as side effects about the medication Rexulti (an antipsychotic medication used to treat agitation).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the kitchen freezer was maintained at a temperature of 0 degrees Fahrenheit ( F) and below, per facility's policy and procedure (P&P). This failure had the potential to result in widespread foodborne illnesses with the residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure two of four sampled residents (Resident 17 and Resident 33), had their call light within reach. This failure had the potential to affect the residents' ability to request assistance when needed.

Inspectors wroteBased on interview and record review, the facility failed to post an accurate nurse staffing information of actual hours worked by Registered Nurses (RN), License Vocational Nurse (LVN) and Certified Nurse Aides (CNA) per shift on 2/23/2026 up to 3/3/2026 in accordance with the facility's policy and procedure titled Posting Direct Care Daily Staffing Number. This deficient practice of posting inaccurate nurse staffing information misinforms the residents and responsible parties about sufficient staffing ratio per residents to meet their needs which affects their quality of care.

Inspectors wroteBased on interviews and records reviews, the facility failed to ensure certified nursing assistants (CNA) were competent in providing appropriate care and services during resident transfers, to and from the bed, for two of three sampled residents (Resident 1 and Resident 2) who underwent orthopedic surgery (a procedure on the musculoskeletal system [a complex of network of bones, muscles, joints, tendons, and ligaments that work together to provide support, movement, and protection to the body) This deficient practice had the potential to place residents at risk for further injury and delay healing process. A review of Resident 1's general acute care hospital (GACH) records, dated 10/13/24, prior to the admission to the facility, indicated Resident 1 was status post fall with left femur fracture, status post (s/p) surgery on 10/10/24. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to account for and administer medications as ordered by the physician for two of two sampled residents (Resident 1 and Resident 2), by failing to: 1. Account for Resident 1 ' s Dilaudid 4 mg tablet bubble pack (also known as a blister pack, a card that packaged doses of medication within small, clear plastic bubbles [or blisters] for easy and safe administration) and the Controlled Medication Count Sheet (CMCS, form used to keep track of how much of a controlled medication was on hand, how much was given to a resident, and how much remained) for the bubble pack. 2. Administer Resident 2 ' s Alprazolam 0.25 mg tablet on 5/4/2025 at 3:30 AM (55 minutes earlier than what was ordered by the physician). 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care and services as ordered by the physician and as indicated in the facility's policy and procedure for one of three sampled residents (Resident 1) after experiencing a fall on 4/4/25 and reported having pain on 4/6/25. Resident 1's x-ray (a medical imaging test that creates images of the inside of the body) that was ordered by the physician 4/6/25 at 7:48 AM due to the resident's complaint of pain on the ankle and x-ray was taken on 4/7/25 at 10:59AM. The facility did not follow up to with the Radiology (company that specialize in x-rays) company of the resident's x-ray to obtain the x-ray result. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the facility's trash bin was not overflowing. The facility disposed trash in a bin with overflowing trash and the trash was on the ground of the facility's parking lot. These deficient practices had the potential to attract pest and rodents, that could spread infection and create an uncomfortable environment for residents, staff and the public.

Inspectors wroteBased on observation, interview and record review, the facility failed to put an opening date on an open pack of ground beef in the facility's one of one freezer. These deficient practices had the potential to cause food-borne illnesses to 54 residents residing in the facility who receives their daily meals prepared in the facility's kitchen.

Inspectors wroteBased on interview and record review, the facility failed to ensure that Resident 53's Advance Directive Acknowledgment Form (a written instruction, such as a living will or durable power of attorney for health care, recognized under State law [whether statutory or as recognized by the courts of the State], relating to the provision of health care when the individual is incapacitated) was completed upon admission to the facility on 1/7/2025. This deficient practice had the potential to result in misinformation of medical care and treatment and not honoring resident's wishes in cases where the resident and/or responsible party was unable to participate in making healthcare decisions.

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the facility's policy for one of one sampled resident (Resident 53) with a diagnosis of diabetes mellitus (a disease in which the blood sugar levels are too high). The facility failed to ensure all appropriate discharge orders from General Acute Care Hospital (GACH) 1 were verified with the attending physician (Physician 1) upon readmission to the facility on [DATE]. This deficient practice resulted to Resident 53 not receiving the care and services to continue diabetic management and/or medications for the resident ' s diagnosis of diabetes mellitus, while in the facility from 12/8/2024 to 1/12/2024 (36 days). Cross Referenced to F641, F657, and F692

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS - a federally mandated resident assessment tool) was accurate for one of one sampled resident (Resident 53) who had a diagnosis of diabetes mellitus (a disease in which the blood sugar levels are too high) with no physician orders for Diabetes Management. This deficient practice had the potential to result in Resident 53 not to receive appropriate treatment and/or services. Cross Referenced to F635, F657, and F692

Inspectors wroteBased on interview and record review, the facility failed to ensure the care plan was revised for one of one sampled resident (Resident 53) who had an active care plan for a diagnosis diabetes mellitus (a disease in which the blood sugar levels are too high) with no physician orders for Diabetes Management. This deficient practice had the potential to result in Resident 53 not receiving appropriate treatment and/or services for the Diabetes. Cross Referenced to F635, F641, and F692

Inspectors wroteBased on interview and record review, the facility failed to ensure a comprehensive approach in regard to resident's diet for one of one sampled resident (Resident 53) by failing to ensure an accurate nutritional assessment was completed for Resident 53 ' s diagnosis for diabetes mellitus (DM- a disease in which the blood sugar levels are too high). This deficient practice had the potential to result in Resident 53 to not receive the appropriate diet and nutritional needs that addressed her DM. Cross Referenced to F635, F641, and F657

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure one (1) of 1 sampled resident (Resident 15) was receiving the appropriate oxygen flow rate in liters per minute (LPM; measurement of volume delivered, used to measure delivery of oxygen) for chronic respiratory failure (when not enough oxygen passes from your lungs to your blood) as ordered by the attending physician and in accordance with the resident's plan of care. This deficient practice had the potential for Resident 15 not to receive enough oxygen or receive too much oxygen which can lead to oxygen toxicity (a condition that occurs when someone breathes in too much oxygen, damaging the lungs and other organs).

Inspectors wroteBased on interview and record review, the facility failed to ensure that the attending physician responded to a recommendation made by the consultant pharmacist (CP) regarding laboratory monitoring for one of four residents (Residents 18) sampled for medication regimen review between 1/9/2024 and 1/9/2025. This deficient practice had the potential to cause a negative impact on the resident ' s overall physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe, sanitary environment to help prevent the spread of transmission of infections to residents, staff members, visitors in accordance with the facility's policy and procedure on infection control by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 1 was aware when to wear personal protective equipment (PPE) in an Enhanced Barrier Precaution (EBP- an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes) room for one of one sampled resident (Resident 49) who had an EBP. 2. Ensure LVN 1 disposed of soiled PPE in a disposable bin inside of Resident 49 ' s room. These deficient practices had the potential to increase the risk of the spread of infection to the residents, staff, and other visitors in the facility.

Inspectors wroteBased on interview and record review the facility failed to provide adequate supervision to one of four sampled residents (Resident 1) who has a diagnosis of dementia (a progressive state of decline in mental abilities), Guillain-Barre syndrome (a neurological condition causing muscle weakness or paralysis [the loss of the ability to move some or all of the body]) and was assessed as a high risk for falls by failing to: 1. Increase the residents ' need for supervision, including the development of an individualized care plan indicating the frequency of supervision to be provided to the resident after the first fall at the facility on 10/22/24, as indicated in the facility ' s policy and procedure [P&P] titled Safety and Supervision of Residents. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide necessary care and services to ensure the resident's ability to perform activities of daily living (ADL) do not diminish for one of three sampled residents (Resident 1) who was dependent with staff on personal hygiene, toilet use and ADL. Resident 1 was left wet with urine for a long period of time, not kept clean and dry as indicated in the resident's care plan and the facility's policy and procedures. As a result of this deficient practice Resident 1 was placed at risk for skin breakdown, infection and feeling frustrated that could result in a decline in ability to perform activities of daily living.

Inspectors wroteBased on interview and record review, the facility failed to implement the facilities policy and procedure titled, Abuse Prevention Management, and Reporting Policies by failing to complete in the facility's employment application (reference section) regarding the previous employer(s), and the facility did not contact the employee's previous employer or references for the employee's character or any history of abuse prior hiring five of five randomly selected employees (Registered Nurse 2 [RN 2], Licensed Vocational Nurse 4 (LVN 4), LVN 3, Certified Nurse Assistant 2 [CNA 2], and CNA 1). This deficient practice had the potential to hire employees with history of abuse, and result in abuse, neglect or mistreatment of residents which could lead to harm and abuse of residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the Minimum Data Set (MDS: a standardized assessment and care-screening tool) was accurate for two of three sampled residents (Resident 4 and Resident 56) for the use of physical restraints (any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body). 1. For Resident 56, Minimum Data Set (MDS) dated [DATE] reflected an accurate assessment of the resident's discharge destination. Resident 56, who was discharged home was coded in the MDS assessment as being discharged to a general acute care hospital (GACH). 2. [...]

Inspectors wrote3. A review of Resident 34's Face sheet (a document that gives a patient's information at a quick glance) indicated an admission to the facility on [DATE] with diagnoses that included aftercare following joint replacement, anxiety disorder, and major depressive disorder. A review of Resident 34's History and Physical assessment dated [DATE], indicated Resident 34 had the capacity to understand and make decisions. A review of Resident 34's Order Summary Report (a physician's order) indicated the following: a. On 2/9/2023, the physician ordered Resident 34 to receive Bupropion (Wellbutrin) Hydrochloride (HCl) Tablet Extended Release 24 Hour 150 milligrams (mg-a unit of measure) one tablet by mouth one time a day for depression manifested by self-report of feeling sad. b. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the necessary care and services for two of two sampled residents (Resident 4 and Resident 159 ) who are high risk for developing pressure injuries (areas of damaged skin caused by staying in one position for too long which reduces blood flow to the area and cause the skin to die and develop a sore) by failing to set the Alternating Pressure Mattress (mattress that provides pressure redistribution by filling and un-filling air cells within the mattress so that contact points with the body are reduced) according to the resident's weight as indicated in the manufacturer's recommendation. Resident 4's body weighs 170 pounds (lbs.-a unit of measurement) Resident 159's body weight of 220 pounds. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 3 of 3 sampled residents (Resident 7, 108 and 47) receiving oxygen therapy were provided respiratory care and resident safety in accordance with the facility's policy and procedure and professional standard of practice by failing to: 1. Ensure proper placement of Resident 7's oxygen tubing and nasal cannula tubing (flexible plastic tubing used to deliver oxygen through nostrils and the tubing is fitted over the patient's ears) was administered continuously and not placed in a storage bag. 2. Ensure Resident 108's nasal cannula was placed properly by placing both nasal prongs in the resident's nostrils; one prong of the nasal cannula was observed in the resident's nostril. [...]

Inspectors wrote3. A review of Resident 11's admission Record indicated Resident 11 was admitted to the facility on [DATE] with diagnoses that included chronic pulmonary edema (a condition caused by too much fluid in the lungs), essential primary hypertension (a condition in which the force of the blood against the artery walls is too high). A review of Resident 11's History and Physical Assessment, dated 12/23/2023, indicated Resident 1 has the capacity to understand and make decisions. A review of Resident 11's Order Summary Report dated 1/14/2024, indicated a physical order for the resident to receive Apixaban (a medication known as blood thinner and reduce blood clot formation) oral (by mouth) Tablet 5 milligrams (mg, unit of measure), give one tablet by mouth two times day for A-fib with a start date of 12/19/2023. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow proper sanitation and safe food handling based on the facilities policy and procedure by failing to ensure: 1. The Dietary Supervisor wore hair net while in the kitchen. 2. The opened bag of five dozen corn tortillas found in refrigerator were dated on when it was opened. 3. The Main [NAME] 1 changed gloves while preparing grilled cheese sandwich, opening drawer to grab spatula, and then proceeding to touch grilled cheese sandwich with the same gloves. These deficient practices had the potential to put residents at risk for foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins).

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a safe, sanitary environment to help prevent the spread and transmission of infections to residents, staff members, visitors in accordance with the facility's policy and procedure on infection control by failing to: 1. Ensure Registered Nurse (RN) 2 wore the N95 respirator mask (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of air particles) that covered the nose and mouth while in the facility during an active Coronavirus (COVID-19, an infectious disease caused by the severe acute respiratory syndrome corona virus 2 (SARS-CoV-2 virus)) outbreak. 2. Ensure used face shields (a plastic covering the face) by staff were disposed after use. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote and treat one of two sampled residents (Resident 159) with respect, privacy and dignity by failing to ensure Resident 159's foley catheter bag (a small flexible, rubber tube that is placed through your skin into the kidney to drain your urine) was left covered to provide resident privacy. These deficient practices had the potential to cause Resident 159 to feel embarrassed that could lead to a psychosocial (mental and emotional well-being) decline, resident's individuality, self-esteem, and self-worth.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide reasonable accommodation of need for one (1) of 14 sampled resident (Resident 2) who was at risk for fall, by failing to ensure the resident's call light (a device used to call for assistance) was within reach as indicated in Resident 2's Care Plan and the facility's policy and procedure, titled Answering the Call Light. This deficient practice had the potential for Resident 2 not to receive or received delayed care to meet the necessary care and services that could result in fall and accident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 159) with suprapubic catheter (a hollow flexible tube that is used to drain urine from the bladder.) had an active physician's order for the indication of placement for suprapubic catheter and the necessary care and treatments while in use. This deficient practice had the potential for Resident 159 with a suprapubic catheter to experience UTIs and had the potential to cause actual harm.

Inspectors wroteBased on interview and record review the facility failed to prevent unnecessary use of medication by failing to assess for depression (depression, mood disorder that causes a persistent feeling of sadness and loss of interest that can interfere with daily life) and monitor the side effects (undesired effect of medication) for one (1) of 1 resident (Resident 1) who was receiving Duloxetine (a type of antidepressant medication, used to treat depression and anxiety). As result of this deficient practice, Resident 1 and other residents receiving psychotropic medications (any medication that affects behavior, mood, thoughts, or perception) could develop side effects that are not detected or continues to receive the medications even when the indication for the use of psychotropic medications had been resolve.

Inspectors wroteBased on interview and record review, the facility failed to ensure prompt efforts were made to resolve grievances verbalized by a family member (Family 1) by one of two sampled residents (Resident 1) and keep Family 1 appropriately apprised of progress towards resolution. In addition, the facility failed to issue a written grievance decision to Resident 1 and Family 1, in accordance with the facility ' s policy on Grievance/Concern. This deficient practice increased the risk for negative psychosocial impact on Resident 1 ' s quality of life.