Solano Post Acute

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of ten sampled residents (Resident 2) was free from physical abuse when Resident 1 hit Resident 2 in the face with a plastic basin. This failure had the potential for Resident 2 to feel unsafe in the facility resulting in a decreased quality of life. A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in July 2026 with multiple diagnoses including cellulitis (bacterial skin infection) of left leg, sepsis (body's extreme response to infection causing tissue damage and organ failure) psychosis (mental state where person loses touch with reality), and schizophrenia (mental illness marked by hallucinations, delusions, and disorganized thinking). [...]

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of physical abuse to The Department within the regulatory time frame and to provide a 5-day investigative report to The Department when two of ten sampled residents (Resident 1 and Resident 2) were involved in an altercation. This failure resulted in The Department not being aware of the incident with the potential for further abuse to occur. A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in July 2026 with multiple diagnoses including cellulitis (bacterial skin infection) of left leg, sepsis (body's extreme response to infection causing tissue damage and organ failure) psychosis (mental state where person loses touch with reality), and schizophrenia (mental illness marked by hallucinations, delusions, and disorganized thinking). [...]

Inspectors wroteBased on interview and record review, the facility failed to investigate an allegation of abuse for two of ten sampled residents (Resident 1 and Resident 2), when Resident 1 hit Resident 2 in the face with a plastic basin. This failure had the potential for abuse to continue if causes are not identified and interventions not implemented. A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in July 2026 with multiple diagnoses including cellulitis (bacterial skin infection) of left leg, sepsis (body's extreme response to infection causing tissue damage and organ failure) psychosis (mental state where person loses touch with reality), and schizophrenia (mental illness marked by hallucinations, delusions, and disorganized thinking). [...]

Inspectors wroteBased on interview and record review the facility failed to protect one of 2 residents sampled for abuse (Resident 1) when Resident 1 was punched in the face multiple times by Resident 2. This failure resulted in Resident 1 sustaining minor injuries to the left eye area. A review of the facility's SOC 341(Report of Suspected Dependent Adult/Elder Abuse) dated 6/21/26 report indicated, Resident 1 was allegedly hit by his roommate Resident 2 as reported by Resident 1 to his family member. A review of Resident 1's Facesheet indicated Resident 1 was admitted to the facility in 2026 with a stroke affecting his left side of his body. A review of Resident 2's Facesheet indicated Resident 2 was admitted to the facility in 2026. [...]

Inspectors wroteBased on the interview, and record review, the facility failed to implement its abuse prevention policy for two out of ten sampled residents, when Resident 1 and Resident 2 were continued to be roomed together after Licensed Nurse (LN 1) witnessed Resident 2 touching Resident 1 in his bed and Resident 1 had a left eye injury with bleeding that was not previously observed. This failure had the potential safety risk for Resident 1 and increased the likelihood of resident-to-resident abuse.

Inspectors wroteBased on interview and record review, the facility failed to timely report abuse-related incident for two out of ten sampled residents (Resident 1 and Resident 2), when Licensed Nurse (LN 1) witnessed Resident 2 touching Resident 1 in his bed, and Resident 1 had a left eye injury with bleeding that was not previously observed. This failure delayed the investigation by the Department and increased the likelihood of abuse for Resident 1.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure three of 7 sampled residents (Resident 2, Resident 7 and Resident 5) was offered and had access to sufficient fluids to maintain hydration when:Resident 2 was observed with dry lips and a dry tongue, with a dry cup present on the bedside table, and no fluids available. During the observation period, no staff were observed offering or providing fluids to the resident,Resident 7's water pitcher was not within reach, and;Resident 5's water pitcher was not refilled in a timely manner. These failures had the potential to result in inadequate fluid intake and negatively affect the residents' hydration status. 1. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the call light (a device that allows residents to communicate with nursing staff when they need assistance) was within reach for three of 7 sampled residents (Resident 7, Resident 5 and Resident 4). This deficient practice had the potential to result in Resident 7, Resident 5 and Resident 4 to not be able to call facility staff for help or assistance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents received necessary assistance with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing, and toileting a person performs daily to care for themselves), including turning and repositioning and timely incontinence care, for two out of seven sampled residents (Resident 1 and Resident 2) when:Resident 1 was not repositioned and provided incontinence care in accordance with the care plan, as evidence by a prolonged gap without repositioning and toileting care, andResident 2 did not receive any assistance with repositioning, comfort, or incontinence care during the observation period, as no such care was observed. [...]

Inspectors wroteBased on observations, interview and record review the facility failed to provide a safe, sanitary environment for five Residents (Resident 1, Resident 2, Resident 3, Resident 4, and Resident 5) in a census of 159 when flies were found in the rooms of all five residents. These findings compromised the residents' right to receive care in a clean, safe, and dignified setting, and increased the risk for infection, cross contamination, and created an unsanitary environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored and labeled appropriately and correctly when:1. Loose pills, non-medication items, bisacodyl suppositories (a stimulant laxative), and a tube of triamcinolone cream (topical corticosteroid for itching, redness or swelling) were found in the 400 Even medication cart,2. Bisacodyl suppository and brownish residue were found in the 600 Hall medication cart,3. Expired over-the-counter (OTC) medications were found in medication room [ROOM NUMBER], and;4. Two medications found at Resident 1's bedside table. These failures had the potential for medication misuse, drug diversion, and diminish medication effectiveness.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that food was stored in accordance with professional standards for food service for a census of 161 residents when food items in freezer #1 were expired or not properly sealed. These failures had the potential to cause food borne illness.

Inspectors wroteBased on observation and interview, the facility failed to ensure six of 32 sampled residents (Resident 1, Resident 81, Resident 67, Resident 68, Resident 114 and Resident 122) residents' rights were respected when:1. Resident 1, Resident 81, Resident 67, and Resident 122 were not informed ahead of time of the construction plan and the significant noise associated with it and, 2. The facility threw away food brought in by the Resident 68 and Resident 114's family. These failures caused anxiety among the residents and resulted in residents not getting enough rest and had the potential to result in the residents not attaining their highest practicable physical, psychosocial, and emotional well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infection prevention measures were implemented for a census of 161 when:1. Resident 156's nebulizer mask was unbagged and undated on the bedside dresser,2. Resident 93's foley bag was on the floor,3. Resident 20, Resident 170 and Resident 163's catheter tubing was on the floor,4. Resident 47's distilled water for CPAP (continuous positive airway pressure-a breathing machine designed to increase air pressure, keeping the airway open when the person breathes in) was not labeled with a date and stored on the floor,5. Resident 47's oxygen tubing was not labeled with a date, and;6. Resident 81's nasal cannula was wrapped around the side rail and not securely stored in an oxygen tubing storage bag. These failures had the potential to cause the spread of infection among a vulnerable resident population.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement an effective pest control program for 20 out of 32 sampled residents (Resident 37, Resident 133, Resident 97, Resident 98, Resident 22, Resident 91, Resident 135, Resident 31, Resident 111, Resident 16, Resident 129, Resident 30, Resident 1, Resident 67, Resident 29, Resident 63, Resident 83, Resident 81, Resident 142, and Resident 9) when gnats (tiny flying insects) and flies were observed in their rooms. This deficient practice had the potential to create unsanitary conditions for the residents, staff, and visitors.

Inspectors wroteBased on interview and record review, the facility failed to provide treatment and services to maintain mobility and prevent further decrease in range of motion for one of 32 sampled residents (Resident 134), when Resident 134 did not receive restorative nursing assistant (RNA, exercises to improve or maintain resident's functional abilities) services per her care plan interventions. This failure placed Resident 134 at risk for further complications and decline in their physical functioning and mobility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure an environment free from accident hazards for one resident (Resident 93) when two beds in the room were situated side by side and put together, for a census of 161. This failure increased the risk of Resident 39 getting caught between beds risking injury and had the potential to cause blocked access for the staff when providing resident care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that pharmacy services were maintained when:1. Controlled drug (medication that may be abused or cause addiction) record form for Resident 63 was not signed immediately after medication administration, and;2. LN did not follow the correct dilution protocol for the intravenous (IV antibiotic for Resident 61). These failures resulted in Resident 61 not receiving the correct dose of IV antibiotic and had the potential to result in diversion of the resident's medication.

Inspectors wroteBased on interview and record review, the facility failed to report an alleged abuse within the prescribed time frame within two hours for one of four residents (Resident 1), when the resident's allegations of inappropriate touching by another resident and a staff member was not reported to the state agency after the charge nurse was notified. This failure resulted to the delayed investigation of the allegation and had the potential to result in Resident 1's emotional and psychological distress. Resident 1 was admitted to the facility in the summer of 2025 with multiple diagnoses which included left and right hemiplegia (left and right-side paralysis) and dysarthria (difficulty speaking). During a review of the Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 6/29/25, the MDS indicated Resident 1 had no memory impairment. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to timely investigate and report the results of investigation of abuse allegations within five days for one of four sampled residents (Resident 1), when Resident 1 complained of being inappropriately touched by another resident and by a staff member. This failure resulted to the delayed investigation of the allegation and had the potential to result in Resident 1's emotional and psychological distress and further abuse. Resident 1 was admitted to the facility in the summer of 2025 with multiple diagnoses which included left and right hemiplegia (left and right-side paralysis) and dysarthria (difficulty speaking). During a review of the Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 6/29/25, the MDS indicated Resident 1 had no memory impairment. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure one of three sampled residents (Resident 1) was free from accident hazards when Resident 1 eloped (the act of leaving a facility unsupervised and without prior authorization) from the facility. This failure had the potential for Resident 1 to be at risk of injury including heat or cold exposure, dehydration, medical complications, and being struck by a motor vehicle.

Inspectors wroteBased on observation, interview and record review, the facility failed follow their policy and procedures (P&P) and to assure that services being provided met professional standards of quality for one of four residents, (Resident 1), when a Licensed Nurse (LN 1) administered medication four hours late, improperly disposed of medication and incorrectly documented these errors. These deficient practices had the potential to cause harm and have a negative impact on the intended therapeutic effect of the medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure an injury of unknown source was reported within the required timeframe for one of five sampled residents (Resident 2) when an injury of unknown source was reported to the California Department of Public Health (CDPH) the following day. This failure of timely reporting had the potential to cause a delayed response by enforcement agencies to ensure resident safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respect and dignity for two of seven sampled residents (Resident 4 and Resident 7), when staff did not label Resident 4 and Resident 7's clothing. This failure had the potential to result in the residents' clothing being lost.

Inspectors wroteBased on observation, interview, and record review, the facility failed to safely administer medications in accordance with acceptable professional standards of quality for one of five sampled residents (Resident 1), when Resident 1 was found in his room with unattended medications at his bedside table. This failure decreased the facility's potential to prevent medication errors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices for a census of 150 residents, when Licensed Nurse 1 (LN 1) did not conduct hand hygiene after leaving Resident 1's room. This failure decreased the facility's potential to prevent the spread of infections among residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention and control program for a census of 153 residents when: 1. A facility staff exited a droplet isolation precaution room (an isolation precaution implemented when a patient infected with a pathogen which is transmittable through air droplets by coughing, sneezing, talking, and close contact with an infected patient's breathing) and removed his used gloves and isolation gown in the hallway where staff and residents were passing by; 2. Two facility staff did not change their N95 mask respirator (a type of mask that filters up to 95% of particles in the air) upon exiting a droplet isolation precaution room; and, 3. A facility staff entered a droplet isolation precaution room and assisted a COVID19 positive resident without using eye protection. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents' medical care was supervised by a physician for one out of eight sampled residents (Resident 5) when the facility did not notify Resident 5's physician when Resident 5 refused blood draw and diagnostic test. This failure had the risk for Resident 5's physician to not be aware about Resident 5's condition and for Resident 5 to not receive appropriate and timely treatment.

Inspectors wroteBased on interview and record review, the facility failed to provide quality and timely laboratory services for one out of eight sampled residents (Resident 5) when Resident 5's laboratory tests ordered on l/8/24 and 2/16/24 were not done. This failure had the risk for the facility to be not aware about critical laboratory values of Resident 5 and for Resident 5 to not receive appropriate and timely treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide quality of care and treatment for one of four sampled residents (Resident 1) when Resident 1 was not informed of medication changes and didn't receive her diuretic (treatment for edema and swelling) medication per assessment, plan of care and physician's order. This failure had the potential to result in a negative outcome.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the physician's order for a dressing change around an Intravenous Central Line (IVCL, flexible tube inserted into a vein to the heart and used to administer medications or nutrition) every 7 days for one of four sampled residents, Resident 1. This deficient practice may potentially cause a life-threatening infection to Resident 1.

Inspectors wroteBased on observation, interview and record review, the facility failed to properly discard a used syringe for one of four sampled Residents (Resident 1), when the used syringe was observed on Resident 1's bedside table. This failure had the potential for Resident 1 and facility staff to accidentally poke themselves and cause injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident needs were accommodated for four of 31 sampled residents (Resident 11, Resident 96, Resident 28, and Resident 234), when the residents did not have their call lights within reach. This failure had the potential to result in residents not attaining their highest practicable physical, psychosocial, and emotional well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of 31 sampled residents (Resident 11, Resident 254, and Resident 280) received respiratory care consistent with professional standards of practice, physician orders, and care plans, when: 1. Resident 11 did not receive oxygen as ordered and as care planned; 2. Resident 280's nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) was not in place; and 3. Resident 254 had no physician's order for oxygen therapy and nasal cannula was not in place. These failures caused Resident 11 to experience shortness of breath and had the potential to result in respiratory distress for Resident 11, Resident 254, and Resident 280.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe and effective pharmaceutical services for a census of 155 residents when: 1. Resident 71 and Resident 255's controlled drug (drug with potential for abuse) use and removal signed out from Controlled Drug Record (CDR- a paper log of controlled drug removal for administration to resident) was not documented in their Medication Administration Record (MAR-a legal document that list administered drugs) and Resident 53's controlled drug use documented in the MAR was not accurately signed out in Resident 53's CDR, 2. Resident 11 received 15 doses of insulin (a medication used to treat high blood glucose level) past the discard date and Resident 71 received 16 doses of expired medication, 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were properly labeled and stored in accordance with the facility's policies and procedures (P&P), and accepted professional principles for a census of 155 when: 1. A total of 5 loose pills were found in 100 hallway medication cart, 700 hallway medication cart, and 400-Odd Hallway med cart; 2a. Two opened insulin medication (a medication used to treat high blood glucose level) passed the discard date were found stored in 100 hallway medication cart; 2b. An expired bubble pack (a form of packaging where an individual pushes individually sealed tablets through the foil to remove the medication) of buspirone (a medication used to treat feeling of fear, dread, and uneasiness) was found stored in 300 hallway medication cart; 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 11 of 31 sampled residents' (Resident 1, Resident 8, Resident 50, Resident 57, Resident 77, Resident 91, Resident 96, Resident 97, Resident 238, Resident 239, and Resident 240's) meal tray ticket (guidance to staff on what to serve for a meal to a resident) was accurate and followed. This failure had the potential to negatively impact all 11 residents' nutritional status, and not provided meals consistent with their preferences.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide palatable, attractive, and appetizing food at preferred temperatures for eight of 31 sampled residents (Resident 1, Resident 8, Resident 15, Resident 39, Resident 60, Resident 83, Resident 121, and Resident 130), when, residents stated the food was cold, bad, and late. These failures resulted in residents' dissatisfaction with their meals and had the potential for decreased food intake leading to unplanned weight loss, nutritional deficiencies, and delayed healing from illness or injury.

Inspectors wroteBased on observation, interview and record review the facility failed to store, and distribute food in accordance with professional standards for food service safety for a census of 155 residents when: 1. Several staff did not wear hair nets and did not perform hand hygiene upon entering the kitchen: a. Maintenance Director (MDir); b. Registered Dietician (RD); c. [name of company] food delivery driver; and e. Dietary Manager Assistant (DMA) 2. Assorted expired food products were found in the walk-in freezer and dry storage room: a. Opened container of mayonnaise with net contents of 3.78 lbs., unlabeled with open and use by date; b. Expired cilantro in a plastic bag dated 11/25/24; c. Expired corn meal in bag with a net weight of 25 lbs. with use by date 8/13/24; d. Expired [brand name] Iced Tea in a box with a net weight of 6 lbs. with use by date 10/17/24; and e. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infection prevention measures were implemented for a census of 155 when: 1. Personal Protective Equipment (PPE- clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) was not worn by housekeeping staff when cleaning a room with Enhanced Barrier Precautions (EBP) (infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs- bacteria that resist treatment with more than one antibiotic] that requires gown and glove use); 2. Staff was observed putting dirty linen into the clean linen storage closet; 3. Resident 1, 36, and 58 urinals were observed stored on the floor with no date or resident label; 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an accurate Minimum Data Set (MDS - an assessment tool used to guide care) assessment for one out of 31 sampled residents (Resident 254), when Resident 254's admission MDS oxygen (O2) therapy assessment was inaccurate. This failure resulted in inaccurate health status data for Resident 254 and the potential for Resident 254 to not achieve his highest practicable well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of 31 sampled residents (Resident 97 and Resident 103) received care which met professional standards when: 1. Family reported to licensed nurse that Resident 103 had an injury of unknown origin on 12/2/24 and was not documented in the nursing notes until 12/3/24; and 2. The facility did not obtain authorization for physical therapy treatment. These failures resulted in inaccurate assessment documentation and had the potential to result in unmet nursing needs for Resident 103 and had the potential to cause a decline in Resident 97's activities of daily living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) and worsening weakness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food that accommodates resident's needs and preferences for two out of 31 sampled residents (Resident 130 and Resident 240) when: 1. Resident 130 was not served coffee during the 12/3/24 breakfast meal; and, 2. Facility did not accommodate Resident 240's preference of decaffeinated (decaf) coffee. These failures had the potential to negatively affect Resident 130 and Resident 240's meal intake.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide clean and non-soiled privacy curtains and failed to ensure the windows were clean and washed, in one of three resident rooms occupied by Residents 2 and 3. These failures resulted in Residents 2 and 3 living in an unclean environment.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse within two hours to the Department and failed submit an investigative summary of the abuse allegation within five working days to the Department, for one of two abuse allegations. These failures had the potential to delay the Department's investigation of the abuse allegation.

Inspectors wroteBased on observation, interview and records review, the facility failed to complete a Fall Risk Assessment for one (Resident 4) of four residents (Resident 4, Resident 5, Resident 6, Resident 7) prior to developing interventions to reduce the risk of falls. This failure had the potential for facility staff not knowing what appropriate and personalized interventions to implement to prevent residents from falls that may result in injuries.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to implement its smoking policy (a facility's set of ideas or a plan for action for smoking) and failed to follow the smoking interventions identified in the Smoking Risks Assessment form (an assessment carried out for people who smoke) and smoking care plan (CP, a formal process that correctly identifies existing needs and recognizes a client's potential needs or risks created for individual residents), for two out of two sampled residents (Residents 1 and 2), to promote safety while they were smoking. These failures were a safety hazard and could result in accidents, burns and smoke inhalation injuries.

Inspectors wroteBased on interviews and record reviews, the facility did not ensure: 1. Resident 1 got to her medical appointment for one out of three sampled residents (Resident 1). 2. Resident 1 and her Responsible Party (RP, an appointed person who could act on behalf of the resident) was notified the facility was not able to procure transportation going to and from the medical appointment, for one out of three sampled residents (Resident 1). These failures could lead to miscommunication, frustration and could be a safety risk due to delayed care and treatment.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure for one out of two sampled residents (Resident 2): 1. An abuse allegation was reported timely. 2. Staff were aware of the abuse allegation reporting time frame. 3. The alleged staff was suspended after an abuse allegation was made. These failures were a safety risk and could result in the abuse to continue and had Resident 2 feeling scared and upset.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate supervision during resident smoking sessions to reduce the risk of elopement. This failure resulted in one of one sampled residents (Resident 10) from being able to elope from the facility, potentially causing great bodily injury.

Inspectors wroteBased on interviews and record reviews, the facility failed to arrange for the appropriate mode of transportation service for one of two sampled residents, Resident 1, when she needed a consult with an OB/GYN (Obstetrics/ Gynecology- An OB/GYN, meaning obstetrician gynecologist, is a medical doctor who combines two disciplines: obstetrics and gynecology. Gynecology is the care of a woman's reproductive organs and health. Obstetrics involves the treatment of pregnant women, including the delivery of babies), as ordered by Physician A, due to vaginal bleeding. This failure had the potential to result in an undiagnosed cause of the bleeding and could affect the health and well-being of Resident 1.

Inspectors wroteBased on interview and records review, the facility failed to ensure one of 12 residents (Resident 1) was free from abuse when Resident 2 hit Resident 1 during an altercation. This failure had the potential to cause pain, physical harm, or mental anguish to Resident 1.

Inspectors wroteBased on interviews and record reviews, the facility failed to: 1. document and perform a root cause analysis on how one out of two sampled residents (Resident 1) sustained the bruising (an injury that doesn't break the skin but results in some discoloration) on her eye; and, 2. ensure it provided immediate notification and consult with the physician, when one out of two sampled residents (Resident 1) was noted with bruising on her eye area. These failures could result in serious outcomes, medical complications, transfer to hospital and death.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure residents' needs were anticipated and frequently needed items, such as water, was within reach for one out of two sampled residents (Resident 1), which resulted in Resident 1's fall on 1/31/24. This fall incident resulted in a small cut on her left index finger. This fall could also put Resident 1 at risk for further fracture (a break in the bone) and pain.

Inspectors wroteBased on interview and record review, the facility did not ensure one five sampled residents (Resident 5), with excessive weight loss, was provided with adequate care to prevent further weight loss. This resident lost 19% of her admission body weight in less than four months. This had the potential to result in harm and could have contributed to Resident 5 ' s death at the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure clinical documentation for one of three sampled residents (Resident 3) was complete and accurate, when activities of daily living (ADLs-Activities related to personal care such as dressing, bathing and toileting) were not documented for Resident 3 several days of December 2023. The documentation did not reflect Resident 3 ' s care and services provided by unlicensed staff to ensure information was available to facilitate communication among the Interdisciplinary Team. This finding had the potential to result in inability for administrative and regulatory staff to monitor the provision of essential ADLs to Resident 3.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure one of three sampled residents (Resident 1) was treated with respect and dignity, when one staff member (Licensed Staff A) refused to wait for Resident 1 to be ready for medication administration and attempted to pull away the prepared medication before Resident 1 could take it. Resident 1 stated Licensed Staff A grabbed and squeezed her right arm, in an act of anger, while trying to remove the medication cup from Resident 1 ' s hand, although the veracity of this act was inconclusive. This finding had the potential to result in serious harm, and feelings of impotence, frustration, and sadness to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate an alleged violation, in response to an allegation of staff-to-resident abuse, for one of three residents (Resident 1). This finding had the potential to result in incidents of abuse to other residents of the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 3) was provided with activities of daily living (ADLs Activities related to personal care such as dressing, bathing and toileting), when Unlicensed Staff C did not provide incontinence care (Cleaning the skin and changing the soiled undergarments and clothing of people with bowel or bladder incontinence [inability to control urination and defecation]), and repositioning, for more than two hours during the night shift of 12/17/23-12/28/23, even though she had been notified that Resident 3 needed to be cleaned-up. This finding had the potential to result in shame, impotence, and the development of pressure ulcers (Injuries caused by pressure on the skin) to Resident 3.

Inspectors wroteBased on observation, interviews, and record reviews, the facility did not provide one of three sampled residents, Resident 1, a resident who was unable to carry out some ADLs (Activities of Daily Living- e. g. showers, bed baths, etc.), the necessary services to maintain good grooming and personal hygiene, when Resident 1 reported to this surveyor that the last shower she got was approximately a year ago, and was not given any explanation why she was only getting bed baths instead of showers. This failure resulted physical harm to Resident 1 as evidenced by the presence of skin conditions such as rashes, open lesions, and dry and scaly skin.

Inspectors wroteBased on observation and interview, the facility failed to ensure food items were stored in a manner that complied with food handling practices to prevent food-borne illness (illness caused by the ingestion of contaminated food or beverages), when two expired items (cereals and onions), beyond their, Use by dates, were not removed from the dry storage area of the kitchen. This failure had the potential to result in the rapid growth of pathogenic (capable of causing disease) microorganisms (e. g. bacteria, virus etc.) that could cause food-borne illnesses and could affect the residents of the facility.

Inspectors wroteBased on interviews and record reviews, the facility failed to report an abuse allegation to the law enforcement agency for one out of two sampled residents (Resident 1). This failure could lead to risk of ongoing abuse and could put residents ' safety at risk.

Inspectors wroteBased on observation, interviews and records review, the facility failed to provide verbal or written notice to three of three sampled residents (Resident 1, 3, and 4) or their representatives before changing rooms for Residents 1, 2, and 3. This failure prevented the Residents or their representatives to exercise their right to agree or disagree with the room change or choose a room according to their preference.

Inspectors wroteBased on interviews and records review, the facility failed to follow its policy and report an alleged violation of abuse within two hours to the California Department of Public Health (CDPH), when Licensed Staff A witnessed Resident 2 kick Resident 1 ' s left leg. This failure had the potential to prevent the State Department to ensure a complete investigation was initiated timely.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure: 1. an abuse allegation was investigated for one out of three sampled residents (Resident 1) on two separate occasions on these dates: 2/2023 and 9/19/23; and, 2.facility staff was aware of the correct reporting time frame for abuse allegations. These failures put the residents at risk for further potential abuse as the alleged perpetrator had continued access to the alleged victim and/or other vulnerable residents. It also resulted in Resident 1 feeling abused, angry, upset, and unsafe.

Inspectors wroteBased on observation, investigation and record review, the facility failed to ensure residents were receiving care to prevent pressure ulcers and did not develop pressure ulcers, for one out of three sampled residents (Resident 1). This failure resulted in Resident 1 acquiring a Stage 4 pressure ulcer (PU, the most serious type of pressure ulcer. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure it provide needed care and services that were resident-centered, in accordance with the residents' preferences, and professional standards of practice, for four out of six sampled residents (Residents 1, 5, 6 and 7) when: 1. staff would leave medications at residents ' bedside, would crush medications without a physician order and would not notify residents of medication changes (Residents 1 and 6); 2. the facility did not have an adequate supply of towels and linens readily available for residents' use (Residents 1, 5, 6 and 7); 3. staff were not providing consistent oral care for the residents (Residents 1 and 5); and, 4) staff were on their phones or using an ear bud while providing care to the residents (Resident 1, 5 and 7). These failures led residents to feel annoyed, upset and frustrated. [...]

Inspectors wroteThe facility failed to ensure there were sufficient Certified Nursing Assistants (CNAs) to provide nursing care to the residents for 27 out of 31 days, for the month of 8/2023. This insufficient staffing led to complaints of four out of four sampled residents (Resident 1, 2, 3 and 4 ) about not receiving showers, delayed provision of care, late response to call lights (an alerting device for nurses or other nursing personnel to assist a patient when in need), residents being left soaked in urine and feces and residents feeling upset, angry, humiliated and frustrated.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to provide consistent showers, per facility schedule, for four out of four sampled residents (Residents 1, 2, 3 and 4). This failure resulted in residents looking unkempt, dirty and feeling frustrated. It also put residents at risk for feeling anxious, itchy and irritable and residents could develop skin infections, wounds and skin disease.

Inspectors wroteBased on observation, interview and record reviews, the facility failed to provide care and services to 6 of 14 residents (Resident 3, Resident 5, Resident 6, Resident 9, Resident 10, and Resident 14) according to professional standards, when Resident 3, Resident 5, Resident 6, Resident 9, and Resident 10 were left sitting in their wheelchairs or in their wet adult diapers for long periods or told to go in their adult diapers while waiting to be helped or cleaned; and Resident 14's call light button was left inaccessible to call for assistance. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide appropriate services to maintain or improve mobility when the Restorative Nursing Program (RNA program - nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible) did not provide gait training (training to improve the ability to stand and walk) using a wide based quad cane (cane with a metal base with four feet attached) with the left upper extremity to ambulate (walk) 20 feet with minimum to moderate assistance and close wheelchair follow (pushing a wheelchair closely behind a resident who is training to improve the ability to walk), to maintain the strength of Resident 10's right arm and lower legs. This failure resulted to Resident 10 not getting out of bed for more than three weeks and feeling furious and frustrated.

Inspectors wroteBased on observation, interview and record review, the facility failed to practice infection prevention and control, when two Certified Nursing Assistants (CNAs) did not handle soiled linens and practice hand gloving properly. These failures had the potential to result to spread infections, disease outbreak, further deterioration of clinical problems or death among facility residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to keep four residents safe when: 1. The facility did not revise the plan of care to reflect the IDT (interdisciplinary team) recommendations and did not assess the effectiveness of the interventions to prevent two out of six sampled residents (Resident 15 and Resident 19) from falling as evidenced by: a.) Resident 15 had eight falls within a 11-month period from 4/1/21 to 3/9/22. Resident 15 sustained a hip fracture from the fall on 11/17/21 which required Resident 15 to be sent to an acute care hospital and underwent a surgical repair of the hip fracture. After 11/17/21, Resident 15 had two more falls on 2/25/22 and 3/9/22; and b.) Resident 19 had four falls during a 10-month period from 5/26/21 to 3/10/22. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to implement measures to reduce the risk of disease and infection transmission when the surrounding area of the trash compactor across the kitchen had puddle of brownish-yellow water and trash accumulation with a dead rat under the trash compactor. This failure had the potential to contaminate the foods prepared in the kitchen that could result to a widespread infection/disease for residents.

Inspectors wroteDuring a review of the intake received on 12/21/21 at 4:13 p.m. indicated Resident 275 stated staff never responded to the call light. Resident 275 stated he was left sitting in his own feces for hours. During an interview on 4/04/22 at 11:40 a.m. with Resident 1, Resident 1 stated CNAs took a long time to answer her call light. Resident 1 stated she asked her CNA to change her adult brief on 4/3/22 at around 10:30 p.m. but she was not changed until 2:00 a.m. Resident 1 stated she had incontinence rashes from the past. Resident 1's MDS (an assessment tool completed by clinical staff to identify potential resident problems, strengths, and preferences) dated 3/14/22, indicated Resident 1 had a BIMS score of 13 (Brief Interview for Mental Status - a 15-point cognitive screening measure that evaluates memory and orientation. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide appropriate hygiene to two residents (Resident 37 and 89) out of five sampled residents. This failure resulted in residents having dirty fingernails and not being provided showers per their individual preferences.

Inspectors wroteBased on interviews and record review, the facility failed to ensure two signatures were documented on the controlled drug count sheet for one of three months record of disposed controlled drugs. This failure had a potential to result in diversion (the transfer of a controlled substance or other medication from a lawful to an unlawful channel of distribution or use) of controlled drugs.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement policies and procedures to address the steps in the Medication Regimen Review (MRR) process (a review conducted by the Consultant Pharmacist of all medications given to all residents in order to identify incidents of adverse consequences, potential drug interactions, ineffective therapy and duplicate therapy). These failures resulted in the Consultant Pharmacist's recommendations for 2 out of 5 residents selected for review due to potential unnecessary medications (Resident 12 and Resident 39) were not acted on and had the potential to result in ineffective treatment, overdose, and increased incidents of adverse consequences for all 145 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure 2 out of 5 residents selected for mediation review (Resident 12 and Resident 39) were free from unnecessary medications (any medication when used in excessive dose, for excessive duration, without adequate monitoring, without adequate indications for its use, in the presence of adverse consequences, or any combinations of the reasons stated) when the facility did not document adequate indications for the use of the medication, did not monitor adverse side effects or residents' behaviors for one medication, and did not act on the pharmaceutical recommendations. This failure had the potential to result in increased risk for movement disorders, falls with injury, cerebrovascular adverse events (commonly referred to as stroke), and increased risk of death.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that one of one sampled resident, Resident 110, was given prior notice in writing that he was going to have a new roommate. This failure resulted in Resident 110 feeling angry and being disrespected. This failure also had the potential to result in physical or psychological harm to Resident 1 because the new roommate, Resident 120, had a history of physically aggressive behavior.

Inspectors wroteBased on interview and record review, the facility failed to ensure performance review of every nurse aide at least once every 12 months and provide regular in-service training that comply with the requirement education for Unlicensed Staff H. This failure had the potential to result in poor quality of work, lack of job knowledge and injury to residents due to lack of training.

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure medication error rate was below 5% when Nurse G did not follow the doctor's order regarding administration of medication for Resident 29 which resulted to two medication administration errors out of 28 administration opportunities (7.14%). This failure had the potential to compromise the absorption of the medication and the risk of developing localized infection of the mouth for Resident 29.