South Coast Post Acute

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the option to formulate an advance directive for five of seven final sampled residents (Residents 10, 158, 163, 169, and 213) reviewed for advance directives. * Residents 10, 158, 163, 169, and 213 were not given the option to formulate an advance directive. These failures had the potential to prevent Residents 10, 158, 163, 169, and 213 healthcare and treatment decisions from being honored.

Inspectors wroteBased on observation, interview, facility record review, the facility failed to ensure comfortable water temperatures for seven nonsampled residents (Residents 49, 64, 73, 107, 114, 144, and 184) with the rooms in Hallway A.* Residents 49, 64, and 114 stated their showers were not provided with enough warm water temperatures.* Residents 73, 107, 144, and 184 stated the water temperature in their rooms' adjoining restroom sinks were cold at night. These failures resulted in the residents not being provided water at a comfortable temperature for bathing, hand hygiene, and incontinent cares.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary pain management care and services for three of 35 final sampled residents (Residents 4, 6, and 222) and one of one nonsampled resident (Resident 248). * The facility failed to provide nonpharmacological interventions prior to administration of acetaminophen (a prescription medication used to manage mild pain) to Resident 248. In addition, the acetaminophen medication was administered when the resident's pain level did not meet the ordered parameters for moderate pain. * The facility failed to administer the hydrocodone-acetaminophen (narcotic pain medication) according to the physician's orders for Residents 4 and 222. * Resident 6 did not have a physician's order for a PRN pain medication for pain levels of 5 to 7, out a 0 to 10 pain scale. [...]

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the food prepared for the residents was cooked to preserve nutritive value for 233 of 237 residents receiving food prepared in the kitchen. * The vegetables were cooked more than one hour prior to meal service and held in the steamer with a temperature set on 212 to 220 degrees Fahrenheit. This failure had the potential to affect the nutritive content of the food, and the amount of food the residents consume, potentially resulting in a decrease in residents' food intake leading to poor nutrition and health outcomes.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. * The facility failed to ensure the microwave utilized to warm up the residents' food was in a sanitary condition. * The facility failed to ensure the heavy-duty blender used for puree preparation and clear pitchers were air dried prior to storage. * The facility failed to ensure the kitchenware and kitchen utensils were clean and free of food particles or residue. * The facility failed to ensure the kitchen utensils had smooth, cleanable surfaces and were maintained in good repair. * The facility failed to ensure the cutting boards were maintained in sanitary condition and had smooth, cleanable surfaces. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the medical records were complete and accurate for four of 35 final sampled residents (Residents 8, 178, 189, and 205) and one of three sampled residents (Resident 242) reviewed for closed records were accurate. * The facility failed to ensure Section D of the POLST and the Advance Directive Acknowledgement form were completed accurately for Resident 8. * The facility failed to ensure Resident 178's MAR was complete for the administration of the ertapenem (antibiotic medication) on 7/24/26. * The facility failed to ensure Resident 189's POLST contained the information of Resident 189's healthcare agent as per the resident's advance directive. * The facility failed to ensure accurate and consistent documentation for the monitoring of Resident 205 for opioid overdose. [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to maintain infection control practices to help prevent the development and transmission of diseases and infection. * The facility failed to ensure the decorative water fountain was monitored and maintained to minimize the growth and spread of waterborne pathogens and other contaminants. * Two out of four washing machines were not maintained in a clean and sanitary condition. * The facility failed to ensure the shower room caulking was clean and free from black residue for one of one shower rooms (Shower Room A). * The facility failed to ensure the staff sanitized glucometer before and after checking Resident 64's blood glucose level and before placing it back into the medication cart. These failures posed the risk for transmission of disease causing microorganisms and infections.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the residents and/or resident representatives were provided with the right to self-determination for two of five sampled residents reviewed for unnecessary medications (Residents 6 and 10). * The facility failed to ensure the informed consent for the quetiapine (antipsychotic), sertraline (antidepressant), Ativan ( antianxiety), and risperidone ( antipsychotic) psychotropic medications for Resident 10 included the reason for the use of medications including diagnosis and manifested behavior specific to the resident. * Resident 6's informed consent forms for the lurasidone (antipsychotic) HCl (hydrochloride) and fluoxetine (antidepressant) HCl, failed to include the reason for the use of the psychotherapeutic medications. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to protect the residents' right to be free from physical abuse for two of six final sampled residents (Residents 33 and 204) reviewed for abuse. * Resident 33 was using the facility's telephone when Resident 24 approached and struck Resident 33. * Resident 204 was struck on the head by Resident 104. Mental Health Workers 3 and 4 stated they witnessed the physical altercation involving Residents 104 and 204. These failures to prevent physical abuse had the potential to result in serious injury and/or psychosocial harm to the residents.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure two of five final sampled residents (Residents 6 and 10) reviewed for the unnecessary medications were free from the unnecessary psychotropic medications. * Resident 6's monthly behavior summary for the lurasidone (antipsychotic) HCl (hydrochloride) and fluoxetine (antidepressant) HCl medications were inaccurate for June 2026. In addition, the facility failed to complete the weekly orthostatic blood pressure monitoring for the antipsychotic medication use. * The facility failed to ensure the monthly summary of behaviors targeted for the use of the Ativan (antianxiety), quetiapine (antipsychotic), risperidone (antipsychotic), and sertraline (antidepressant) medications were completed for Resident 10. [...]

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to complete the MDS assessments accurately for two of 35 final sampled residents (Residents 4 and 189). * Resident 4 received oxygen and PRN hydrocodone-acetaminophen (opioid medication). The facility failed to code the use of oxygen and administration of opioid medication in the quarterly MDS assessment dated [DATE]. * Resident 189 had a weight loss of 7.97% (more than 5% in one month). The facility failed to accurately code the weight loss in the MDS assessment dated [DATE]. These failures posed the risk of the residents not receiving the individualized plans of care based on the residents' specific needs.

Inspectors wroteBased on interview, medical record review, and facility document review, the facility failed to comply with the requirements of DHCS as part of the PASRR process for one of two final sampled residents (Resident 10) reviewed for PASRR. * The facility did not complete a Resident Review (Status Change) screening following a diagnosis of schizophrenia for Resident 10. This failure had the potential for Resident 10 to not receive appropriate care and services due to serious mental illness or intellectual disability not being properly identified and evaluated.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive plan of care for one of 35 final sampled residents (Resident 224) was revised to reflect the resident's current care needs and interventions. * Resident 224's care plan for significant weight change was not revised to address the weight interventions as ordered by the physician. This failure posed the risk of not providing the resident with individualized and person-centered care.

Inspectors wroteBased on interview, medical record review, facility record review, and facility P&P review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable well-being for three of 35 final sampled residents (Residents 30, 130, and 224). * The facility failed to ensure the physician was informed when Resident 30 refused her complete blood count (CBC) labs for June 2026. * The facility failed to ensure a skin assessment was conducted for Resident 130 when admitted to the facility. Resident 130 had a skin lesion and the facility failed to provide prompt care and interventions. * The facility failed to ensure the insulin (medication that regulates the amount of sugar level in the bloodstream) injection sites were rotated as ordered by the physician for Resident 224. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide RNA services as ordered by the physician for one of one final sampled resident (Resident 178) reviewed for ROM. * The facility failed to provide documented evidence that the splint for Resident 178 was applied for up to three hours per day as ordered by the physician. This failure had the potential to result in the decline in Resident 178's ROM which could lead to further deterioration in the resident's physical well- being.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the necessary GT care and services for one of four final sampled residents (Resident 9) reviewed for tube feeding. * The facility failed to ensure Resident 9 was positioned safely at 30 to 45 degrees during the enteral feeding via GT. Additionally, the facility failed to ensure Resident 9's water flush connected via feeding pump was labeled. These failures posed the risk for developing complications related to the resident's GT.

Inspectors wroteBased on observation, interview, medical record review, and P&P review, the facility failed to ensure one of two final sampled residents (Resident 4) reviewed for respiratory care were provided the appropriate respiratory care. * The facility failed to ensure Resident 4's nasal canula tubing (dated 7/2/26) was changed weekly as per the physician's order. This failure had the potential to affect the respiratory health and well-being of Resident 4.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to follow pharmaceutical procedures for two of 35 final sampled residents (Residents 4 and 6). * Resident 6's Insulin Glargine (a long-acting insulin) was not administered as ordered by the physician. * Resident 4's controlled medication administration was not appropriately reconciled and documented on the MAR. These failures had the potential for Resident 6 to experience undesirable negative outcomes related to BS levels and resulted in inaccurate controlled medication reconciliation records for Resident 4, with the potential for a controlled medication diversion.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to provide the necessary pharmacy services for two of five medication carts (Medication Carts C and E) to ensure proper storage of the medications. * The facility failed to ensure the orally administered medications were stored separate from the externally used medications in Medication Cart C. * The facility failed to ensure medications brought in from home were labeled and not stored in Medication Cart E. In addition, the facility failed to ensure a multidose insulin vial was labeled when it was opened. These failures had the potential to have negative impact on the residents' well-being, and the potential for the medications to be contaminated, losing the stability and effectiveness.

Inspectors wroteBased on interview, facility document review, and facility P&P review, the facility failed to maintain staffing documentation of the education regarding the risks and benefits and the offering of the COVID-19 vaccine. * CNA 1 was not provided education regarding the risks, benefits and not offered the COVID-19 vaccine . In addition, the facility failed to ensure accurate tracking of CNA 1's vaccination status as per the facility's P&P. This failure placed the residents and staff members at risk for increased risk of infection and transmission of COVID-19.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure one of three glucometers (Glucometer A) was calibrated and the quality control was performed as scheduled. * The facility failed to ensure Glucometer A was calibrated and quality control was performed on 7/27/26. This failure had the potential for residents requiring blood glucose checks to have inaccurate readings.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to protect the residents' right to be free from physical abuse from other residents, for two of six residents (Residents 1 and 4) reviewed for abuse. * Resident 1 was in the hallway speaking with staff when Resident 2 approached and punched Resident 1 on the left cheek, causing a cut to Resident 1's left cheek. * Resident 4 was struck on the head by Resident 3. MHW 1 stated he witnessed the physical altercation involving Residents 3 and 4. These failures to prevent physical abuse had the potential to result in serious injury and/or psychosocial harm to the residents.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the appropriate infection control practices designed to provide the safe and sanitary environment were implemented for two of seven sampled residents (Residents 5 and 6). * The facility failed to ensure CNA 1 performed proper hand hygiene and handling of clean linens when providing care for Resident 5. * The facility failed to ensure LVN 1 performed disinfection of the call light after picking it up from the floor before placing it on Resident 6's lap. In addition, proper hand hygiene must be performed by LVN 1 after handling the call light from the floor. These failures posed the risk for transmission of disease-causing microorganisms and infections.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to protect the resident's right to be free from physical abuse for one of six sampled residents (Resident 3). * Resident 4 pushed and kicked Resident 3 in the abdomen, causing Resident 3 to experience pain and fall to the floor. This failure resulted in Resident 3 experiencing physical pain and potential for psychosocial harm.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive care plan was developed and implemented to reflect the individual care needs for one of six sampled residents (Residents 4). * The facility failed to develop a care plan problem to address Resident 4's childlike behavior, horseplaying and poor boundaries. This failure had the potential for the resident to not be provided with appropriate, consistent, and individualized care.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to develop a care plan for two of three sampled residents (Residents 1 and 2). * The facility failed to develop a care plan for Resident 1's sexual and physical abuse allegations. * The facility failed to develop a care plan for Resident 2 allegedly hitting another resident. These failures had the potential to negatively impact the residents care.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the abuse allegations were thoroughly investigated for two of five sampled residents (Residents 1 and 3). * The facility failed to conduct a thorough investigation for Resident 1's abuse allegation against Resident 2 when the resident's roommate was not interviewed regarding the incident. * The facility failed to conduct a thorough investigation for Resident 3's abuse allegation against Resident 4 when witnesses were not interviewed regarding the incident. These failures had the potential for the residents to be vulnerable for further abuse, mistreatment, and injury.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure a safe and coordinated discharge for one of four sampled residents (Resident 1). * The facility initiated a Discharge AMA (Against Medical Advice) when Resident 1 returned to the facility after being out on pass (on the same day) without a planned place to stay. In addition, Resident 1's Out on Pass Log was incomplete. This failure had the potential to result in an unsafe discharge when Resident 1 experienced a panic attack and was transported to the emergency room.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the Out on Pass Log was accurately and completely filled out for two of four sampled residents (Residents 1 and 4). * Resident 1 and 4's Resident Out on Pass Log did not include the time when the resident went out of the facility, had returned to the facility, and the nurse's initials. These failures had the potential for the residents' care needs to not be met.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed ensure the residents were free from the abuse for two of five sampled residents (Resident 4 and 5). This failures resulted in Residents 4 and 5 having a physical altercation, which had the potential to negatively impact the residents' well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the medical record was accurate for one of five sampled residents (Resident 1). This failure had the potential to negatively impact the resident's care as the medical information was inaccurate.

Inspectors wroteBased on observation, interview, medical record review,facility document review, and facility P&P review, the facility failed to ensure one of 10 sampled residents (Resident 8) was free from abuse. * Resident 8 accidently bumped into Resident 7. In response, Resident 7 got upset and pushed Resident 8 into the wall, causing an abrasion to Resident 8's forehead and a laceration to Resident 8's left eyelid. This failure resulted in Resident 8 sustaining multiple injuries as a result of the altercation, which had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the reporting of a reasonable suspicion of a crime was completed in a timely manner for four of 10 sampled residents (Residents 1, 2, 7, and 8). * The facility failed to ensure Resident 1's physical abuse allegation by MHW 1 was reported timely to the CDPH L&C Program and local law enforcement agency. * The facility failed to ensure Resident 2's verbal abuse allegation by MHW 5 was reported timely to the CDPH L&C Program and local law enforcement agency. * The facility failed to report a resident-to-resident altercation of physical abuse when Resident 7 admitted to assaulting Resident 8 on two different occasions. These failures had the potential for abuse and injury of unknown origin allegations to go unreported and uninvestigated timely.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to implement their P&P for abuse investigation for four of 10 sampled residents (Residents 1, 2, 7, and 8). * The facility failed to immediately remove MHW 1 from duty pending an abuse investigation for Resident 1. * The facility failed to conduct a thorough investigation for Resident 1's abuse allegation against MHW 1 when the resident witnesses were not interviewed regarding the incident. * The facility failed to begin an investigation within two hours following Resident 2's verbal abuse allegation against MHW 5. * The facility failed to implement their P&P to conduct a thorough investigation when Residents 7 and 8 verbalized Resident 7 assaulted Resident 8 on two different occasions. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive care plans were developed and revised for three of 10 residents (Residents 4, 6, and 8). * The facility failed to revise a plan of care for Resident 4's bilateral floor mats for fall prevention. * The facility failed to develop a plan of care for Resident 6's weight loss. * The facility failed to develop the plan of care for Resident 8's facial abrasion following an injury after a physical altercation occurred. These failures had the potential to place the residents at risk of their care needs not being met.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to prevent Resident 1 from injury. * The facility failed ensure Resident 1 was free from injury during the facility's de-escalation process. This failure resulted in Resident 1 sustaining facial and neck bruising, which had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on interview, and medical record review, the facility failed to provide the necessary care and services to maintain the intravenous accesses and properly provide IV care for three of three final sampled residents (Residents 184, 733, and 983) and one nonsampled resident (Resident 932). * The facility failed to ensure Resident 932's IV tubing was free from air bubbles prior to administration. * The facility failed to ensure Resident 184's midline (a long, thin, flexible tube inserted into a large vein in the upper arm used to deliver fluids and medications into the bloodstream) dressing was dated and labeled. In addition, the facility failed to ensure Resident 184's midline was maintained to prevent possible complications. * The facility failed to discontinue Resident 983's PIV line after the antibiotic therapy was completed. [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitation guidelines were followed as evidenced by: * There were white pieces of plastic trash found on the floor, in the sink area of the pots and pans, and in the main food preparation hallway floor area. Additionally, a pair of gloves and dietary menu forms were found in clean serving areas. * The top clean surface of the soup machine had three unwashed cabbages, cooking mittens, two basins, and a cutting board. * Vegetables in a plastic bag fell onto the floor and was picked up and placed on the food cart by the Dietary Assistant Manager. * There were two fryers baskets with brown residue and a serving utensil used as a scooper was found with food residue. Additionally, a can opener had brownish orange residues. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the informed consents were obtained for the use of psychotropic medications for one of five final sampled residents (Resident 147) reviewed for informed consents (Resident 147). * There were no informal consents prior to administering olanzapine (antipsychotic medication), quetiapine (antipsychotic medication), and valproic acid (mood stabilizer medication) to Resident 147. This failure had the potential for the resident to be unaware of the risks associated with the medications which could have adverse side effects detrimental to the resident's well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to maintain a copy of an advance directive in the medical record for one of five final sampled residents (Resident 184) reviewed for advance directives. This failure had the potential for Resident 184's decisions regarding his healthcare and treatment options to not be honored.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the PASRR Level 1 (a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) assessment was coded accurately for two of four final sampled residents (Residents 132 and 147) reviewed for PASRR. This failure posed the risk of the residents not receiving specialized care and services appropriate for their condition.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the individualized and ongoing activity program to meet the needs and interests for one of one final sampled resident (Resident 147) reviewed for activities. This failure had the potential to affect the residents' psychosocial well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary GT care and services for one of three final sampled residents (Resident 735). * The facility failed to ensure Resident 735's GT was checked for placement before administration of the medications and water. In addition, the facility failed to administer each medication and water flushes via gravity. These failures had the potential for the resident to develop complications related to the GT care and management, including tube dislodgement, delayed nutritional feeding, and trauma.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure two of three final sampled residents (Residents 96 and 161) reviewed for respiratory care were provided the appropriate respiratory care. * The facility failed to ensure Resident 96's humidifier was labeled and dated and the resident had the physician's order for oxygen use as per the facility's P&P. * The facility failed to ensure Resident 161's oxygen order was carried out as ordered by the physician. These failures had the potential to affect the respiratory health and well-being of the residents in the facility.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the pharmaceutical services to ensure accurate reconciliation of the controlled medications for three of 35 final sampled residents (Residents 27 and 40) and one of six medication carts (Medication Cart A). In addition, the facility failed to provide the medications and/or biologicals, as ordered by the prescriber, to meet the needs of one of 35 final sampled residents (Resident 735). * The facility failed to ensure the administration of the controlled medications for Residents 40 were accurately reconciled and documented in the MAR. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure two of five final sampled residents (Residents 146 and 147) reviewed for unnecessary medications were monitored for the use of psychotropic medications. * The facility failed to ensure Resident 146's orthostatic blood pressure related to the use of an antipsychotic medication was monitored as ordered by the physician . * The facility failed to ensure non-pharmacological interventions were provided prior to the administration of quetiapine for Resident 147. In addition, the facility failed to ensure Resident 147's behavior for the use of quetiapine medication was monitored and the AIMS assessment was completed. These failures had the potential to negatively impact the residents' well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 25.93%. Two of four licensed nurses (LVN 3 and RN 1) observed during the medication administration were found to have made errors. * LVN 3 failed to ensure the correct dosage of the medication was administered to Resident 735 when residue was observed in each medication cup after administration. In addition, LVN 3 failed to administer the correct physician's order dosage form for one medication to Resident 735. * RN 1 failed to ensure the correct dosage of medication was administered to Resident 932. These failures had the potential to negatively affect the residents' health conditions.

Inspectors wroteSurveyor: [NAME] Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure proper storage, labeling, and disposal of the medications. * The facility failed to ensure the expired medications in Medication Room A's refrigerator were discarded. In addition, the medication refrigerator's temperature was not maintained within the recommended temperature. * The facility failed to ensure the expired oral and external administered medications were discarded in Medication Room C. * The facility failed to ensure the expired oral administered medication was discarded in Medication Cart B. * The facility failed to ensure the expired medication and culture swab kit were removed from the current treatment supply in Treatment Cart A. [...]

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the safe handling and collection of regular waste. * There was scattered food residues on the ground next to the food waste dumpster and the open space storage area had trash such as disposable cups with orange liquid, tortilla plastic container, and piles of leaves. * Two of the six soiled linen barrels were observed with trash inside of them, uncovered, and without a lid; one barrel was overfilled with trash bags and the other barrel contained two bags of trash, with a milky substance spilled at the bottom of the barrel. These failures posed the risk for safety and pest contamination.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the appropriate infection control practices designed to provide the safe and sanitary environment were implemented for two of 35 final sampled residents (Resident 184 and 735) and four nonsampled residents (Residents 64, 118, 151, and 932) * The facility failed to ensure LVN 2 wore proper PPE when administering medication for Resident 184 who had a midline catheter. * The facility failed to ensure proper hand hygiene was performed during medication administration to Resident 151. * The facility failed to ensure proper hand hygiene was performed during medication administration to Resident 735. * The facility failed to ensure the Zosyn (antibiotic) vial's septum was disinfected before connecting to the normal saline mini-bag IV solution for Resident 932. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medical records for two of 35 final sampled residents (Residents 132 and 184) were complete. * The facility failed to document the administration of the piperacillin-tazobactam medication for Resident 184. * Resident 132's MAR had missing documentation on 1/13/25, for the evening shift. These failures had the potential for the residents' care needs not being met as the clinical information was not complete.

Inspectors wroteBased on interview, medical record review, and facility document review, and facility P&P review, the facility failed to protect the resident's rights to be free from the physical abuse by another resident for one of five sampled residents (Resident 1). * Resident 2 punched Resident 1 in the face because Resident 1 would not be quiet. This failure caused Resident 1 to have a broken nose, bruising to his left eye, and bruising to the area around the left eye.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide services to attain or maintain the highest practicable well-being for one of five sampled residents (Resident 4). * Resident 4 was noted with bilateral lower extremities swelling after the administration of intravenous fluids on 12/8/23, and transferred to the acute care hospital ED for abdominal pain and increased abdominal girth on 12/8/23. The facility failed to assess Resident 4's bilateral lower extremities swelling upon Resident 4's return to the facility on [DATE], failed to assess and monitor Resident 4's abdominal girth upon his return from the ED, and failed to obtain Resident 4's weekly weights as ordered by the physician. Resident 4 was transferred to the acute care hospital on [DATE], for elevated temperature and abdominal edema. [...]

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the infection control practices were implemented to help prevent development and transmission of diseases and infections for two of four sampled residents (Residents 3 and 4) and six of six nonsampled residents (Residents 5, 6, 7, 8, 9, and 10). * The facility failed to properly store and label two bedpans and a basin observed on a handrail in Room A's restroom occupied by Residents 5 and 6. * The facility failed to properly store and label a basin found in Room B's restroom occupied by Residents 3, 7, 8 and 9. * The facility failed to properly store and label a urinal found on top of a toilet tank in Room C occupied by Residents 4 and 10. These failures had the potential for cross contamination and spread of infections.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of two sampled residents (Resident 8) maintained the acceptable parameters of nutritional status. * The facility failed to ensure the IDT evaluated and monitored the effectiveness of the intervention implemented after 3/13/24, for Resident 8's unplanned severe weight loss. This failure had the potential for Resident 8's compromised nutritional status was not monitored effectively which could lead to further medical complications.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to establish and maintain the infection control program and practices designed to help prevent the development and transmission of diseases and infections as evidenced by: * The facility failed to ensure the EBPs were followed for Resident 8 when the staff did not wear a disposable gown before providing care to the resident. * The facility failed to ensure the hand hygiene was performed after using the gloves in between the dressing change. These failures had the potential for spread of infections in the facility.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the necessary care and services were provided to prevent the development or worsening of pressure injuries for one of two sampled residents (Resident 8). *Resident 8 developed a Stage 4 pressure injury to the right buttock after admission to the facility. The facility failed to provide the skin treatment to Resident 8's right buttock as ordered by the physician. This failure had the potential for Resident 8 to not receive the appropriate care and services to promote healing of the pressure ulcer.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to promote dignity and respect for four nonsampled residents (Residents A, B, C and D) * The facility failed to ensure the resident's call lights were answered in a timely manner for Residents A, B, C and D. These failures posed the risk to negatively affect the residents' physical and emotional well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the reasonable accommodations to meet the care needs for two of five residents (Residents 1 and 3) reviewed for call lights. * The facility failed to ensure Resident 1's call light was answered in a timely manner. * The facility failed to ensure Resident 3 was assisted promptly or informed of when the resident would get assistant after the staff answered the call light and was unable to fulfill the resident's request. These failures had the potential to negatively impact the resident's psychosocial well-being or result in a delay to provide care and services to the residents.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure Resident 2's medicationswere administered as per physician's order due to a lack of availability of the medications for one of two sampled residents reviewed for medication administration (Resident 2). * LVN 1 failed to ensure Resident 2's Lasix (medication use to treat fluid retention and swelling caused by congestive heart failure, liver disease, kidney disease, and other medical conditions) supply was available for scheduled administration as per the physician's order. * Resident 2 was admitted to the facility on [DATE]. However, the pharmacy failed to deliver Resident 2's prescribed medication for Entresto (a fixed-dose combined medication used to treat heart failure). [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of one reviewed resident (Resident 2) for unnecessary medication was free from the unnecessary psychotropic drug (any drug that affects brain activity associated with mental processes and behavior). The facility failed to ensure Resident 2's physician's order for Seroquel (antipsychotic medication) had a diagnosis justify for the use of medication, implemented nonpharmacological interventions prior to drug use, monitored targeted behavior, and monitored side-effects of the drug use. These failures had the potential for Resident 2 to have adverse complications from the medication and the potential of not providing the correct data to the prescriber in order to adjust the dose of the psychotropic medication for Resident 2.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the privacy was provided for one of one reviewed resident (Resident 1). * The facility failed to ensure Resident 1's adult briefs and bilateral lower extremities were not exposed or seen in the hallway. This failure had the potential to negatively affect the dignity of the resident and violate the resident's right to privacy.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to protect the resident's rights to be free from physical abuse by a resident for one of four sampled residents (Resident 1). * Resident 1 alleged she was shoved and hit on the face by Resident 2. Resident 3 stated he witnessed the physical altercation involving Residents 1 and 2. Resident 3 stated he witnessed Resident 2 push or punch Resident 1 twice in the upper torso region. This failure to prevent the physical altercations between the residents had the potential to cause injury and/or psychological harm to the residents.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to notify the resident's physician immediately after a fall COC as per the facility's P&P for one of six sampled residents (Resident 1) and failed to ensure the physician was informed of the medication not administered as ordered due to the medication was not available for one of six sampled residents (Resident 3). These failures posed the risk for changes in Residents 1 and 3's health conditions not being identified, delay in necessary care and treatment, and the risk for negative health outcomes.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the care plan for falls was reviewed and revised for one of six final sampled residents (Resident 1) as per the facility's P&P. This failure put Resident 1 at risk of not receiving resident-centered care after an unwitnessed fall.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to obtain the resident's vital signs and failed to administer the resident's prescribed medications as ordered by the physician for one of two sampled residents (Resident 1). In addition, the facility failed to notify the resident's physician that the resident's vital signs were not obtained and the resident's medications were not administered as ordered for Resident 1. These failures posed the risk for changes in Resident 1's health condition not being identified, potentially delaying necessary care and treatment, which posed the risk for negative health outcomes to Resident 1.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure Resident 1's medications were administered as per the physician's orders due to a lack of availability of the medications for one of two sampled residents (Resident 1). * Resident 1 was admitted to the facility on [DATE] at 1339 hours; however, the pharmacy failed to deliver Resident 1's prescribed medications until the following day. As a result, Resident 1 did not receive her prescribed medications which were scheduled to be administered on 12/7/23 at 0900 hours. * Resident 1's medical record failed to show Resident 1's physician was notified that Resident 1 did not receive her scheduled medications on 12/7/23 at 0900 hours, in accordance with the facility's P&P. These failures posed the risk for negative health outcomes for Resident 1.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the residents were free from the unnecessary psychotropic medications for eight of 35 final sampled residents (Residents 5, 19, 42, 51, 59, 79, 175, and 182). * The facility failed to ensure the use of of each psychotropic medication had specific behavior manifestations for Residents 5, 19, 42, 59, 79, 175, and 182. * The facility failed to ensure the psychotropic medication behavioral monitoring were accurate, the care plan was revised to reflect the current behavioral manifestation, and the non-pharmacological intervention were documented for Resident 51. [...]

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure proper storage, labeling, and disposal of medications. * The facility failed to ensure the medications for Residents 496 and 497 who had expired, and Residents 38 and 498 who were transferred out of the facility had been removed from the current medication supply in Medication Carts 1 and 2, and Medication room [ROOM NUMBER]. * The facility failed to ensure the discontinued IV medication for Resident 126 had been removed from the current medication supply in the IV cart. * The facility failed to ensure the opened inhalation solution medications for Residents 144 and 901 inside Medication Cart 1 were labeled with an opened date. [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen when: * The leftover (previously served) food was not discarded. * One facility staff (RNA 1) did not use gloves when the resident's food was touched. * The water temperature of the hand sink was less than 85 degrees Fahrenheit (F). * The test strip used to test the sanitizing solution of the manual dishwashing sink had expired. * The food preparation equipment, utensils, and dishware were not airdried. * A drawer which contained clean food preparation utensils was not clean. * One food preparation sink and one steamer did not have an air gap. * A scoop was stored inside a thickener container. * A staff member failed to ensure to put hand gloves before distributing resident's cups for drinks. [...]

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the residents' entrapment assessments were complete during the bed inspection when identifying areas of possible entrapment with the use of bed rails for all 35 residents with the use of side rails. These failures had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure two of 35 final sampled residents (Residents 35 and 912) were provided the opportunity to participate in the care plan conferences. * The facility failed to ensure Resident 35 was offered the opportunity to participate in the quarterly care plan conference. * Resident 912 was not informed of his plan of care. These failures had the potential for Residents 35 and 912 to not be able to choose treatments options and make decisions in care planning.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 35 final sampled residents (Resident 545) who was assessed to not be able to self-administer the medications had the medication in her possession. This failure had the potential to negatively impact the residents' physiological well-being and could administer the medications inaccurately.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to inform and provide the written information regarding the rights to formulate the advance directives to one of 35 final sampled residents (Resident 745). In addition, the facility failed to ensure the Physician Orders for Life Sustaining Treatment (POLST) and advance directives information were accurate for two of 35 final sampled residents (Residents 34 and 129). These failures had the potential for the facility to provide treatment and services against the resident's wishes.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure three of 35 final sampled residents (Residents 34, 121, and 131) were free from the physical restraints. * The facility failed to ensure the physician's order and informed consent were obtained and the care plan problem was initiated for Resident 34's use of a wheelchair lap tray. * The facility failed to ensure the soft hand mittens used for Resident 121 was necessary and had a physician's order and monitoring for behaviors and skin condition. * The facility failed to ensure the least restrictive measures were attempted before the use of bolsters and the restraint elimination assessment was completed for bolsters and pad alarm for Resident 131. [...]

Inspectors wroteBased on interview, medical record review, facility P&P, and DHCS PASRR guidelines review, the facility failed to ensure a subsequent PASRR Level 1 Screening was conducted as required for one of 35 final sampled residents (Resident 51). This failure had the potential for Resident 51 to not receive specialized care and services appropriate for their condition.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the baseline care plan for two of 35 final sampled residents (Residents 745 and 912) were initiated upon admission. * The facility did not provide Resident 745 a copy of the resident's care plan. * Resident 912's baseline care plan was incomplete. The care plan did not include necessary information to properly care for the resident such as bathing or shower while on isolation precaution. These failures placed Residents 745 and 912 at risk of not receiving resident-centered care.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive plans of care for two of 35 final sampled residents (Residents 14 and 51) were revised to reflect the resident's current care needs and interventions. * The facility failed to ensure Resident 14's plan of care was revised to address Resident 14's use of bilateral 1/2 (half)bed side rails. This posed the risk of not providing Resident 14 with the individualized and person-centered care. * The facility failed to ensure Resident 51's plan of care was revised to reflect the change for indication and manifestation for olanzapine (an antipsychotic medication used to treat several mental health conditions). [...]

Inspectors wroteBased on interview and medical record review, the facility failed to provide the activities of daily living care for one of 35 sampled residents (Resident 912). * Resident 912 was not assisted with a shower or bed bath as scheduled for two weeks. This failure had the potential to put Resident 912 at risk for further skin breakdown, infection, and psychosocial harm.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the individualized activity program to meet the needs and interests of one of 35 final sampled residents (Resident 912). This failure had the potential for the resident to experience feelings of social isolation and boredom.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure three of 35 final sampled residents (Residents 51, 79, and 125) attained and maintained their highest practicable well-being. * The facility failed to ensure Resident 79's orthostatic blood pressure (measure the blood pressure while laying down or sitting and again upon standing up) was monitored as ordered by the physician related to the use of an antipsychotic medication. This failure had the potential for the resident to experience adverse consequences from the psychotropic medication. * The facility failed to coordinate the care of Resident 125 with the contracted hospice. The facility failed to conduct a plan of care meeting with Resident 125, the hospice representatives, and facility representatives. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to complete the assessment and initiated a care plan prior to the use of the side rails for one of 35 final sampled residents (Resident 14). This failure had the potential to put Resident 14 at risk for serious injuries.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the pharmaceutical services to ensure accurate reconciliation and administration of the medications for one of 35 final sampled residents (Resident 745) and two nonsampled residents (Residents 902 and 909). * The facility failed to ensure the administration of the controlled medications for Residents 902 and 909 were documented in the MARs. * The facility failed to ensure the change of medication administration instruction sticker was placed on the medication bubble packs when there was a change of order for Residents 745 and 902. These failures posed the risk for diversion of the controlled medications and medication administration errors.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 22.22%. Two of three licensed nurses (LVNs 3 and 7) who were observed during the medication administration were found to have made errors. * LVN 7 crushed and mixed famotidine (medication used to treat stomach ulcers) and metoprolol (antihypertensive medication) in one medication cup and administered the medications together via GT for Resident 40. * LVN 7 failed to ensure the correct dosage of medications were administered when a residue was observed in the medication cup after administering the famotidine and metoprolol via GT to Resident 40. [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the kitchen staff (Dietary Aide 1) was competent to safely perform manual dishwashing. This failure had the potential for dishes used by residents to not be washed correctly which could lead to sanitation concerns.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure one nonsampled resident (Resident 203) was provided with the CCHO (diet for diabetic) diet as ordered. This failure posed the risk for Resident 203 to have an increased blood sugar level .

Inspectors wroteBased on observation, interview, facility document review and facility P&P review, the facility failed to provide to one nonsampled resident (Resident 124) adaptive equipment per physician order for the resident's dietary needs. This failure had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the facility staff and visitors who brought resident food from the outside were educated on safe food handling practices. This failure posed the risk for unsafe food handling which could result in food borne illness.

Inspectors wroteBased on observation, interview, medical record review, and facility document review, the facility failed to implement their infection control program and practices designed to help mitigate the development and transmission of infections in accordance with the facility's P&P. * The facility failed to implement their infection control surveillance program for the SNF from January 2023 through August 2023 and for the TRC from 1/1/23 to 2/4/23. The facility conducted surveillance of resident infections based only on the residents who were prescribed antimicrobials (medication used to treat infections). [...]

Inspectors wroteBased on interview, medical record review, and facility document review, the facility failed to monitor and optimize the use of antibiotics for their residents as per the antibiotic stewardship. * The facility failed to inform the physician of the residents who had not met the McGeer's Criteria (a set of specific definitions to identify the infections in long term nursing facilities) and were prescribed antibiotics for two nonsampled residents (Residents 91 and 161). * The facility failed to accurately report the three nonsampled residents (Residents 15, 846, and 847) for October 2023 and one nonsampled resident (Resident 3) for November 2023 who had Syphilis (a chronic bacterial disease that is contracted by infection during sexual intercourse). Residents 15, 846, and 847 were reported as not meeting McGeer's Criteria in the Infection Prevention and Control Surveillance Log; [...]

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the residents' meal tickets were safeguarded to protect their confidential health information. This failure had the potential for the residents personal and health information to be accessed from the unauthorized users.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the admission assessment MDSs were completed within 14 calendar days of the resident's entry date of admission for two of 35 final sampled residents (Residents 745 and 912) and one nonsampled resident (Resident 198). This had the potential of not identifying each resident's preferences and goals of care, functional and health status, strengths and needs, as well as offering guidance for further assessments once the health problems had been identified.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the MDSs for quarterly assessments were completed within 14 calendar days of the ARDs for three nonsampled residents (Residents 52, 100, and 198). This failure had the potential of not identifying each resident's preferences and goals of care, functional and health status, strengths and needs, as well as offering guidance for further assessments once the health problems had been identified.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the MDSs for one of 35 final sampled residents (Resident 125) and one closed record sampled resident (Resident 243) were accurate. This posed the risk of the residents not receiving an individualized plan of care based on the residents' specific needs.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to develop the comprehensive plans of care to reflect the individual care needs of one of 35 final sampled residents (Resident 35). The facility failed to develop a care plan problem to address Resident 35's refusal of participating in a care plan meeting. This failure posed the risk of not providing appropriate, consistent, and individualized care to Resident 35.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 35 final sampled resident (Resident 913) was provided with the appropriate respiratory care. * Resident 913's nebulizer mask and tubing were not properly stored. This failure had the potential to affect the respiratory health and well-being of Resident 913.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the physician signed the telephone orders timely for one of 35 final sampled residents (Resident 131). This posed the risk for inaccurate treatment for the resident.

Inspectors wroteBased on observation and interview, the facility failed to ensure the garbage was stored in sanitary manner. This failure had the potential for pest contamination.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medical records for three of 35 final sampled residents (Resident 34, 77, and 121) were complete and accurately maintained. * The facility failed to ensure Resident 34's TAR for indwelling urinary catheter care was complete. * The facility failed to ensure Resident 77's pain assesment was documented accurately in the MAR. * The facility failed to ensure Resident 121's skin assessment related to soft hand mitten use was documented in the TAR. These failures had the potential for the resident's care needs not being met as the medical information was incomplete or inaccurate.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the coordination of hospice services for one of 35 final sampled residents (Resident 51). * The facility failed to ensure Resident 51's hospice visitation calendar showed the scheduled hospice staff visits. This failure had the potential to put Resident 51 at risk for uncoordinated medical care between the facility and hospice agency.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of two sampled residents (Resident 1) received care in accordance with professional standards to promote healing of a pressure ulcer. * Resident 1 developed a pressure ulcer on his right heel. The facility failed to provide the treatments and interventions as ordered by the physician and plan of care on the consistent basis. This failure had the potential to delay the resident's healing of the wound.

Inspectors wroteBased on interview and facility document review, the facility failed to ensure the glucometer (medical devices to check resident blood sugar) calibration was performed daily to check the residents blood sugar check accurately. This posed the risk of glucometer malfunction to be undetected.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the grievances from Resident 1 were promptly addressed when Resident 1 expressed the concerns regarding the insulin medication administration, unprofessional staff conduct, and intravenous access. This failure had the potential for Resident 1 to feel hopeless and negatively impact his emotional well-being.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure medications were stored securely when: * There was no system for control and accountability of medications waiting for final disposition for controlled and noncontrolled medications. * The facility failed to check the refrigerator temperature to ensure all medications required to be refrigerated were stored at the appropriate temperatures. These failures posed a potential for diversion of non-controlled medications and controlled medications and had the potential for the residents to receive medications with altered integrity or potency.