St. Andrews

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure fortified diets (meal plan that increases a resident's caloric intake by adding high calorie items) were prepared as prescribed by the physician for five of 10 sampled residents (Resident 16, Resident 21, Resident 42, Resident 46, and Resident 51). This deficient practice had the potential for the residents not to meeting their nutritional needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident representative was informed of the dysphagia (difficulty of swallowing) screening result for one of one sampled resident (Resident 54). This deficient practice violated the resident representative's right to be fully informed of Resident 54's plan of care and had the potential to result in a delay of care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure two physical restraints weren't simultaneously used for one of eight sampled residents (Resident 35). This deficient practice resulted in the use of unnecessary restraints and restricted Resident 35's movement.

Inspectors wroteBased on interview and record review, the facility failed to ensure the use of lorazepam (brand name Ativan, a medication used to treat anxiety and aggressive behaviors) had an adequate indication for use for one of eight sampled residents (Resident 38). This deficient practice had the potential to result in the use of a chemical restraint which could cause oversedation for Resident 38.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, a resident assessment tool) was coded accurately for one of 23 sampled residents (Resident 47) by failing to ensure Resident 47's MDS, dated [DATE], reflected his serious mental illness (a health condition that affects a person's thinking, mood, behavior, or ability to relate to others). This deficient practice resulted in the transmission of inaccurate data to the Centers for Medicare and Medicaid Services (CMS) regarding Resident 47's health status and had the potential to negatively affect the plan of care and delivery of care and services for Resident 47.

Inspectors wroteBased on interview and record review, the facility failed to ensure a quarterly IDT (Interdisciplinary Team- a group of people with different training and skills who work closely together to solve a complex problem or care for someone) meeting was conducted for one of eight sampled residents (Resident 12). This deficient practice resulted in staff not updating Resident 12's care plan.

Inspectors wroteBased on interview and record review, the facility failed to ensure a referral for cardiology (medical specialty focused on the diagnosis, treatment, and prevention of diseases and disorders related to the heart and the cardiovascular system) was completed for one of one sampled resident (Resident 11). This deficient practice had the potential not to keep track of Resident 11's underlying heart disease that could result in the delay of necessary care and services.

Inspectors wroteBased on observation and interview, the facility failed to ensure a floor mat was placed by the bed as ordered for one of eight sampled residents (Resident 3). This deficient practice had the potential to result Resident 3 sustaining injuries during a fall.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident who has a suprapubic catheter (a thin, flexible tube used to drain urine from the bladder) was changed monthly as per the physician's order for one of one sampled resident (Resident 9). This deficient practice had the potential to result in the recurrence of a urinary tract infection ([UTI] - an infection in the bladder/urinary tract) that could develop into urosepsis (a potentially life-threatening complication of urinary tract infection).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of eight sampled residents (Resident 3) with Post Traumatic Stress Disorder (PTSD- a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event) received Trauma Informed Care (TIC- an intervention and approach that focuses on how trauma may affect an individual's life and his or her response to behavioral health). This deficient practice had the potential to result in the staff's inability to identify possible triggers that could result in re-traumatization (the reactivation of trauma symptoms via thoughts, memories, or feelings related to the past traumatic experience) for Resident 3.

Inspectors wroteBased on observation, interview and records review, the facility failed to ensure one of four sampled residents (Resident 24) was free from unnecessary medications when:1. There were two physician orders for Acetaminophen ([Tylenol] used to relieve mild to moderate pain) with the same indication.2. Tramadol (prescription painkiller used to treat moderate to severe pain) was administered routinely without a clinical indication. This deficient practice had the potential to result in medication errors, overdose, and unnecessary use of opioid (prescription drugs used to treat moderate to severe pain and carry significant risks of addiction, dependence, and overdose.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure an unopened Gabapentin (an anticonvulsant drug used primarily to treat nerve pain and seizure) oral solution was stored inside the medication room refrigerator for one of one sampled resident (Resident 35). This deficient practice had the potential for the loss of efficacy of the Gabapentin oral solution that would cause ineffective pain management of Resident 35.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one resident's (Resident 15) dislikes on the dietary card reflected the resident's preference. This deficient practice had the potential to result in dissatisfaction with meals leading to decreased intake and weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to properly store, label and monitor food items for use when: Ravioli was kept in the freezer beyond use by date of 6/1/2026. Tamales was taken out of its original packaging and placed in a zip lock bag without use by date label. These deficient practices had the potential to place residents at risk for foodborne illness (an illness caused by food contaminated with bacteria, viruses, and other toxins).

Inspectors wroteBased on interview and record review, the facility failed to ensure the Arbitration Agreement form (a legally binding contract where parties agree to resolve future disputes through a private, out-of-court arbitration process instead of suing in a traditional courtroom) was not signed by one of eight residents, (Resident 1), who had a responsible party (the individual designated to pay a patient's medical bills, manage their care decisions, or supervise daily support services), had cognitive impairment, did not have the capacity to understand and make decisions and who was legally blind (a government classification for significant vision impairment used to determine eligibility for disability benefits, tax exemptions, and rehabilitation services). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 5 sampled residents, Resident 1, who was on a pureed diet (foods modified to a soft, pudding-like consistency for residents who have difficulty chewing or swallowing solid foods), was not fed by an untrained facility staff (Recepitonist). This failure placed the resident at risk for choking and aspiration (the inhalation of foreign material, like food, liquid, or stomach contents, into the airway and lungs) of food, which could lead to resident injuries and hospitalization, including death.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement its infection prevention and control measures for two of five sampled residents (Residents 3 and 4) by failing to perform hand hygiene (washing hands or using an alcohol-based sanitizer) before and after assisting Resident 3 and Resident 4 with their lunch meals. This failure had the potential to spread germs and increase the risk of infections among residents and staff.

Inspectors wroteBased on observation, interview, and record review, the staff failed to ensure the residents and/or responsible party (RP) were informed of an alleged abuse on 2/24/2025 and dentist visit on 3/10/2025 for one of three sampled residents (Resident 1). The deficient practice led Resident 1 ' s responsible party feeling ignored and uninformed about the care of Resident 1.

Inspectors wroteBased on observation, interview and record review, the facility failed to store food in accordance with professional standards for food service safety by failing to: 1. Ensure food items were labeled in Refrigerator 1, Refrigerator 2, Refrigerator 3 and Freezer 2 in the kitchen. 2. Ensure expired food was discarded from Refrigerator 2 in the kitchen. 3. Ensure a dented can sign was on display in the dry storage area. 4. Ensure the kitchen mixer and processer was clean. 5. Ensure the juice dispensing nozzle was clean. This deficient practice had the potential to result in in foodborne illness and contamination.

Inspectors wroteBased on interview and record review, the facility failed to revise and provide an updated average daily census of the Facility Assessment Tool (a process for evaluating a facility's resident population and identifying the resources needed to provide care and services). This deficient practice had the potential to place residents at risk for delay of care and treatment services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistance to one of three sampled residents (Resident 8) who had ill-fitting clothing, exposing the resident's buttocks. This failure had the potential to negatively affect Resident 8's sense of self-worth and self- esteem.

Inspectors wroteBased on observation interview and record review, the facility failed to honor snack preferences for one of five sampled residents (Resident 34). This deficient practice resulted in Resident 34 not being able to make choices about his preference for food.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the physician for one of three sampled resident (Resident 11) who was refusing range of motion (ROM- full movement potential of a joint where two bones meet) therapy. This failure had the potential for Resident 11 to decline in physical functioning and resulted in delayed continuity of care due to the physician not being notified in a timely manner.

Inspectors wroteBased on observation interview and record review, the facility failed to ensure the responsible party/Power of Attorney was notified of Medi-Cal approval for one of five sampled residents (Resident 46). This deficient practice had the potential to result in the responsible party not being able to make medical decisions for the resident.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Transmit the Minimum Data Set ([MDS]- a resident assessment tool) within 14 days after completion to the Center of Medicare and Medicaid Services (CMS) for one of 20 sampled residents (Resident 53). This deficient practice had the potential to result in a billing error and inaccurate data on resident care needs.

Inspectors wroteBased on interview and record, the facility failed to ensure an accurate Minimum Data Set ([MDS] - a resident assessment tool) assessment was completed accurately for two of 20 sampled residents (Resident 3 and 27) by failing to: 1. Esure Resident 3's Trazodone (medication used to treat depression) was not encoded as a hypnotic (a class of psychoactive drugs that treat insomnia and help people fall asleep) under MDS Section N (N0415 High-Risk Drug Classes) for medication. 2. Ensure Resident 27's weight loss was not encoded as significant weight loss (loss of 5 percent ([%] - out of each 100) or more in the last month or loss of 10% or more in last 6 months) under MDS Section K (K0300 Weight Loss). [...]

Inspectors wroteBased on interview and record review, the facility failed to complete and re-submit the Preadmission Screening and Resident Review ([PASARR - a tool to determine if the person had, or was suspected of having a mental illness, intellectual disability, or related condition) Level one (I) screening and refer one of three sampled residents (Resident 33) who had a diagnoses of anxiety disorder (a condition that involves excessive and persistent feelings of fear, dread, and worry that can interfere with daily life) and major depressive disorder ([MDD] - a mood disorder that causes a persistent feelings of sadness and loss of interest) to the appropriate state-designated authority for PASARR Level two (II) evaluation and determination. This deficient practice had the potential to result in Resident 33 to not receive the appropriate medical treatments for mental illness diagnoses.

Inspectors wroteBased on interview and record review, the facility failed to properly obtain an accurate orthostatic blood pressure (a form of low blood pressure that happens when standing after sitting or lying down) readings for one of one sampled resident (Resident 10). This deficient practice had the potential to result in Residents 10 experiencing a delay in interventions if they were positive for orthostatic hypotension (low blood pressure).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the low air loss mattress settings were correct for one of five sampled residents (Resident 5). This deficient practice had the potential to result in further skin breakdown.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate services to prevent a decline in joint range of motion ([ROM] - full movement potential of a joint) for one of four sampled residents (Resident 50) who had limited range of motion by failing to: 1. Provide a left-hand roll (a device that prevents fingers from curling up tightly). This deficient practice had the potential to result in further decline in Resident 50's ROM and overall quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a driver's license was renewed in a timely manner for one of five sampled residents (Resident 46). This deficient practice had the potential to result in a delay in the delivery of care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 3) did not receive an opened capsule of Duloxetine (a medication used for depression and nerve pain). This deficient practice had the potential to result in Resident 3 to experience adverse effects due to the nurse not following the medication manufacturer's directions.

Inspectors wroteBased on interview and record review, the facility failed to follow the physicians orders to draw monthly labs for a Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP) and Keppra level for one of two sampled residents (Resident 25). This deficient practice had the potential to result in a delay in care and services due to missing laboratory results.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide at least 80 square feet ([sq. ft.] unit of measurement) per resident in multiple resident bedrooms for 11 out of 23 resident rooms. The insufficient space had the potential to result in and lead to inadequate nursing care to the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure one out of four sampled residents (Resident 2) had a Care Plan (a documentation that outlines a patient's care and is created by a nurse as part of the nursing process) for physical aggression (behavior causing or threatening physical harm towards others). This deficient practice of not having a Care Plan for physical aggression had the potential for Resident 2 to be physical aggressive again.

Inspectors wroteBased on interview and record review the facility failed to ensure the physician order was followed for one out of four sampled Residents (Resident 1). This deficient practice of not following physician orders placed the Resident 1 at risk for continuing aggressive behavior after an altercation (a noisy argument or quarrel between people which could include fighting).

Inspectors wroteBased on interview and record review, the facility failed to develop a resident-centered care plan for the use of foley catheter (flexible tube that drains urine from the bladder into a collection bag) for one of three residents (Resident 1). This deficient practice had the potential to result in poor quality care on a resident with foley catheter, placing the resident at risk for urine infection and other catheter usage complications (blockage, sediments).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff implemented the fall prevention care plan for one of two sampled residents (Resident 2). This deficient practice increased the potential for avoidable physical harm to Resident 2 related to a repeat fall with possible injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure fall prevention interventions were implemented, as indicated in the care plan, for one of two sampled residents (Resident 2). This deficient practice increased the potential for avoidable physical harm to Resident 2 related to a repeat fall with possible injury.

Inspectors wroteBased on observation, interview, and record review, Licensed Vocational Nurse (LVN) 1 failed to administer medications according to the facility ' s policy and procedure (P&P) for one of two sampled residents (Resident 2). This deficient practice created the potential for Resident 2 to take medications affecting his blood pressure and heart rate, without his blood pressure or heart rate being within the required range for safe administration. The failure also created the potential for Resident 2 ' s medications to be taken by a facility resident the medications were not ordered or intended for.

Inspectors wroteBased on interviews and record review, the facility failed to notify resident representative for one of four sampled resident ' s (Resident 1, after Resident 1 was found on the floor. This deficient practice resulted in Resident 1's representative not aware of the fall incident.

Inspectors wroteBased on interviews and record review, the facility failed to ensure staff supervision was provided to one of four sampled residents (Resident 1), who was left on the floor alone, after a fall, while the other staff called for assistance. This deficient practice had the potential to cause further injury to Resident 1 and Resident 2, who put Resident 1 back to bed.

Inspectors wroteBased on interviews and record review, the facility failed to maintain accurate documentation for one of four sampled residents (Resident 1). This failure resulted to an inaccurate documentation for Resident 1 ' s incident.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow its policy and procedure to replace the non- antibiotic Emergency Kit (E-Kit) within 72 hours. This deficient practice had the potential for not providing medication to residents during emergency situations.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food items were labeled properly and expired food was not stored in the kitchen accessible to be used in preparing foods for 45 out of 51 residents. This practice had the potential to result in the residents ingesting expired food and can result in foodborne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to document and maintain a temperature log of two out of two clothes dryers (dryer 1 and 2). This deficient practice had the potential to result in spread of infection (the invasion of growth of germs in the body) throughout the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure a peripheral catheter ([IV], a thin tube inserted into a vein for therapeutic purposes such as administration of medications, fluids and/or blood products) dressing was dated for one of one sampled resident (Resident 152). This deficient practice had the potential for the IV insertion site to develop an infection and/or hospitalization for Resident 152.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure respiratory care was consistent with professional standards of practice when there was no physician order to administer oxygen for one of two sampled residents (Resident 152). This deficient practice had the potential to result in unsafe use of oxygen equipment, respiratory infection, unable to breathe comfortably, and/or hospitalization for Resident 152.

Inspectors wroteBased on interview and record review, the facility failed to ensure a competency assessment skill (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics in performing that an individual need to perform work roles or occupational functions successfully) checks performed upon hire and annually for two out of five randomly selected staff. This deficient practice had the potential for the facility not be able to assess the skills necessary to provide nursing services to assure resident safety and to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident will not be performed within the acceptable standards of practice.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure the order for a psychotropic medication (drug that affects behavior, mood, thoughts, or perception) as needed (PRN), was not limited to 14 days per regulation for one out of three sampled residents (Resident 43). This deficient practice had the potential to result in the use of unnecessary medication, or non-therapeutic use of psychotropic mediation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Label and remove one opened expired ipratropium with albuterol (a combination medication used to treat and prevent shortness of breath) inhalation solution for Resident 40. 2. Remove expired opened ipratropium (atrovent inhaler) with albuterol solution for Resident 45. These deficient practice had the potential to result in prolonged use and loss of strength of the expired inhalation solution and can lead to ineffective treatment of respiratory symptoms and possibly can cause severe adverse reactions (an unintended effect of a medication that is harmful or unpleasant) including hospitalizations.

Inspectors wroteBased on observation, interview, and record review, the facility failed to document insulin injection location sites of administration for one out of seven residents (Resident 101). This deficient practice had the potential to result in skin and tissue damage if injection sites were not rotated.

Inspectors wroteBased on interview and record review, the facility failed to meet the required 80 square feet (sq ft) for each resident in multiple resident bedrooms for 11 of 23 resident's rooms. The resident rooms included rooms 1, 3, 4, 5, 6, 7, 8, 9, 10, 14 and 16 which did not meet the regulation, placing the residents at risk for lack of privacy, safety concerns during care, and emergency services.

Inspectors wroteBased on interview and record review, the facility failed to implement its abuse policy and procedure (P&P) by failing to ensure an allegation of physical abuse was reported to the California Department of Public Health (the Department) within two hours for one out of three sample residents (Resident 1). This deficient practice had the potential for a delay in the Department ' s investigation of the abuse allegation and placed Resident 1 at risk for further abuse.