St. John of God Retirement

Inspectors wroteBased on interview, and record review, the facility failed to implement the Care Plan for one of three sampled residents (Resident 2) which indicated to monitor Resident 2's location and document the resident's wandering behavior and attempted diversional interventions in the behavior log. This deficient practice resulted in Resident 2 having an altercation with Resident 1, after Resident 2 entered Resident 1's room and had the potential to result in injuries and harm to Residents 1 and 2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain complete and accurate medical records according to professional standards for one of four sample residents (Resident 2), by failing to ensure Resident 2's wandering behaviors and episodes of agitation were documented. This deficient practice had the potential to result in a lack of communication between staff and a delay in provision of care or interventions for Resident 2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the California Department of Public Health (CDPH) was notified of an injury of unknown origin (an injury that was not witnessed and cannot be explained by the affected individual) for one of three sampled residents (Resident 4). This failure of not reporting the injury of unknown origin to CDPH within two hours delayed the investigation and placed Resident 4 at risk for further injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a care plan (a personalized document outlining a patient's health needs, medical history, and specific goals for care) for the use a Korean-speaking interpreter for one of three sampled residents (Resident 4) when Resident 4 expressed discomfort to her left lower leg. This failure of not implementing the care plan had the potential for Resident 4 to not effectively communicate with staff regarding her injury.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure an informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) was obtained from resident representative prior to initiation of psychotropic drug (Any drug that affects brain activities associated with mental process and behavior) for one of one sampled resident (Resident 1). This deficient practice had the potential for the resident representative to have a lack of knowledge to make an informed consent and not knowing in advance the potential risk and benefits of the psychotropic drug.

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 three sampled residents (Resident 3). This deficient practice resulted in the transmission of inaccurate data to the Centers for Medicare and Medicaid Services (CMS) regarding Resident 3's health status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a care plan was developed to reflect an order for floor mats (cushioned floor pads designed to help prevent injury should a person fall) for one of three sampled residents (Resident 1), related to the resident's high risk for falls. This deficient practice placed Residents 1 at risk of not having floor mats at the bedside, and placed the resident at risk for injuries related to potential falls. Cross Reference F689.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure fall prevention interventions, such as the use of floor mats and bed alarms and wheelchair alarms (a safety device that sounds an alert to caregivers when someone attempts to get out of bed, helping to prevent falls), were implemented for one of three sampled residents (Residents 1 and 2), who were at risk for falls when: 1. Resident 1 did not have floor mats at the bedside, as ordered, following a fall on 8/11/2025. 2. Resident 1's physician was not notified in a timely manner of the resident's refusal of bed and wheelchair alarms. 3. A fall risk evaluation was not conducted for Resident 2 following her fall on 1/11/2026. These deficient practices placed Residents 1 and 2 at risk for falls and associated injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to:Label and discard food items in two of three sampled refrigerators. Ensure test strips used to test sanitation strength were not expired. These failures had the potential to increase the risk of foodborne illness in the residents.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide a competency assessment (a skill or ability, especially one required to perform a particular job or role) for four of four CNA's. This failure had the potential to result in untimely and inaccurate weights and improper range of motion for the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure narcotic (controlled medication) drug records were accurate for Med Cart 3 for Resident 15 and Med Cart 4 for Resident 49. 2. Ensure 2 signatures were obtained on a narcotic destruction form for Resident 146. This deficient practice had the potential to result in medication errors and medication diversions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to:Label multi-use medication bottles (a container that holds a drug for multiple doses) with an open date in four of seven sampled medication storage areas (Medication Storage room [ROOM NUMBER], Medication Cart 2, Medication Cart 3, and Medication Cart 4). Refrigerate an opened Acidophilus (drug that maintains healthy bacteria) bottle in one of four sampled medication carts (Medication Cart 1). These failure had the potential to result in resident harm due to the weakened strength of the medication and the administration of ineffective drug dosages.

Inspectors wroteBased on observation, interview, and record review, the facility failed to:1. Perform hand hygiene (cleansing hands with soap or an alcohol-based rub) before assisting two of two sampled residents (Resident 68 and 144).2. Ensure one of one sampled residents (Resident 1) gastronomy tube ending was capped off to prevent contamination. This failure had the potential to expose Resident 68 and Resident 1 to potentially infectious organisms.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the temperature in the residents' rooms were within range for two of two sampled residents (Resident 63 and Resident 120). This failure had the potential to negatively affect the residents' quality of life.

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 26 sampled residents (Resident 5 and Resident 130) by failing to: 1. Ensure Resident 5 and Resident 130's Gabapentin (medication used to treat seizure and nerve pain) was encoded as anticonvulsant medication. This failure had the potential to negatively affect the plan of care and services for Resident 5 and Resident 130.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Develop a comprehensive person-centered care plan for anti-fungal (a drug that kills or stops the growth of harmful fungi causing infections in humans) medication for one of one sampled resident (Resident 143). This deficient practice had the potential not able to monitor the side-effect (undesired effects of a drug) of antifungal medication that could possibly harm Resident 143.

Inspectors wroteBased on observation, interview and record review, the facility failed to review and revise one of two sampled residents (Resident 76) when her condition changed. This failure had the potential to result in inappropriate plan of care, outdated treatments, and patient centered goals not being met.

Inspectors wroteBased on observation, interview and record review, the facility failed to:Ensure low air loss mattress settings were accurate for two of 16 sampled residents (Resident 1 and Resident 3).

Inspectors wroteBased on observation and interview, the facility failed to: 1. Ensure continuous supervision was provided for one of eight sampled residents (Resident 32). This deficient practice had the potential to result in injuries and accidents.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure one of one sampled resident (Resident 13) was provided with Bladder training (type of training that will help a person manage urinary incontinence). This deficient practice had the potential for decline in bladder function for Resident 13.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure the oxygen tubing (flexible tube that delivers oxygen-rich air) was not kinked (bent) for one of one sampled resident (Resident 109). This failure had the potential to result in decreased oxygen flow (to move continuously) to Resident 109.

Inspectors wroteBased on observation, interview and record review, the facility failed to assess the pain for one sampled resident (Resident 112), in accordance with the facility policy and procedure for pain management. This failure had the potential to negatively impact Resident 112's quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the weekly nursing assessment for one of three sampled residents (Resident 56) was accurate. This failure resulted in inaccurate medical documentation with the potential to cause delayed or incorrect treatments, missed diagnoses or even medication errors for Resident 56.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the hospice (compassionate care for people who are near the end of life provided at the person's home or within a health care setting) services meet professional standards for one of four sampled residents (Resident 15) by failing to: 1. Ensure a hospice calendar with the scheduled visits for the hospice team was available. This deficient practice had the potential to result in a delay or lack of coordination in delivery of hospice care and services to Resident 15.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 81) call light was within reach. This failure had the potential to result in Resident inability to access the call light for assistance or emergency.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a pack of cigarettes was not left unattended on the bench in the facility's patio (the designated smoking area). This failure had the potential to pose a risk of fire or a serious incident to residents due to unattended cigarettes.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure a contingency plan (a pre-defined set of actions to be taken if an original plan fails or an unexpected event occurs) was developed and included in the Facility Assessment (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 for the facility to ineffectively respond during unexpected circumstances and negatively impact resident care.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure the Infection Preventionist (a person designated by the facility to be responsible for the infection prevention and control program) Nurse (IPN) attend, participate and give findings on a regular basis to Quality Assessment and Assurance ([QAA] develop and implement appropriate plans of action to correct identified quality deficiencies) committee. This deficient practice had the potential to negatively impact resident safety and unable to monitor infection control practices and outcome of the facility.

Inspectors wroteBased upon observation, interview and record review, the facility failed to: 1. Report to the California Department of Public Health [CDPH]- the state department responsible for public health in California) an injury of unknown origin for one of three sampled residents (Resident 1). This deficient practice resulted in a delay of an onsite investigation by CDPH and had potential to place all residents at risk for abuse.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive Care Plan for one of four sampled residents (Resident 1) who was receiving heparin (an injected medication given that prevent the formation of blood clots). This deficient practice had the potential for unidentified interventions for Resident 1 and placed the resident at risk for side effects and complications from the medication such as bleeding.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food items were discarded after the use by date. The following items were as follows: 1 Baking Soda Powder dated 12/6/2022 and use by date 12/6/2023. 2. Colander Seeds dated 6/21/2022. 3. Red Food coloring opened date 6/16/2023 with no use by date. 4. Package of breadcrumbs open date 5/14/2024 and use by date 7/14/2024. This deficient practice of having expired dry food items had the potential to result in harmful bacteria growth that could lead to foodborne illness for residents who received food and drinks from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement appropriate infection control practices when: 1. The facility did not follow their policy and procedure (P&P) for washing the laundry in the correct temperature range. 2. In the rehabilitation office, two resident reusable cold modality packs and two staff food containers in the refrigerator were stored in the same combination freezer/refrigerator. 3. Restorative Nursing Aide (RNA 1) did not properly disinfect a cloth gait belt (an assistive device that is secured around a person's waist to allow a caregiver to grasp the belt and assist in lifting or moving a person) during a treatment session with Resident 63. These deficient practices have the potential to spread infections among residents, staff, and visitors.

Inspectors wroteBased on observation and interview, the facility failed to post the complaint investigation results by California Department of Public Health ([CDPH] state licensing and certification agency) during the three preceding years in the areas of the facility that are prominent and accessible to the residents, family members, and visitors. This deficient practice placed the residents, family members or visitors at risk of not knowing the status of the facility non-compliance outcome results and past performance history.

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 annually for four 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 observation, interview, and record review, the facility failed to indicate the opened date on the label for medications (to be administered Residents 124, 131, 98, 7, and 23) stored in two of four sampled medication carts. This deficient practice had the potential for residents to experience adverse effects from the administration of expired medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one out of eight sampled Residents (Resident 47) was properly dressed daily. This deficient practice of not dressing Resident 47 daily had the potential of leaving Resident 47 feeling low self-worth and low self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light (a device with a button that, when pressed, alerts healthcare providers that assistance is required) was within reach for one out of 30 sampled residents (Resident 14). This deficient practice had the potential to result in Resident 14 not being able to call for assistance and a delay in necessary care and services affecting resident's well-being.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician of a significant weight loss (a weight loss greater than 5% in one month, greater than 7.5% in three months and greater than 10% in 6 months) of 18 pounds ([lbs.] unit for measuring weight) 11.8 percent [%] in three months (Resident 24), and failed to notify the physician of a resident's swollen ankles for two of two sampled residents (Resident 24 and Resident 39). This deficient practice had the potential to place Resident 24 at risk for further weight loss, and placed Resident 39 at risk for further complications of ankle swelling. Cross reference F656.

Inspectors wroteBased on interview and record review, the facility failed to ensure an accurate Minimum Data Set ([MDS] a federally mandated resident assessment tool) was completed accurately for two of 30 sampled residents (Resident 14 and Resident 81) by failing to: 1. Ensure Resident 14's mental illness diagnosis was reflected in the MDS assessment under Section A (Level II Preadmission Screening and Resident Review [PASRR] a tool to determine if the person had or was suspected of having a mental illness or intellectual disability) conditions. 2. Ensure Resident 81's Minimum Data Set [MDS] a federally mandated assessment tool) was updated quarterly. These deficient practices resulted in incorrect data transmitted to Center for Medicare and Medicaid Services (CMS) and had the potential to result inaccurate care and services for Residents 14 and 81.

Inspectors wroteBased on interview and record review, the facility failed to correctly fill out the Preadmission Screening and Resident Review ([PASRR] a tool to determine if the person had, or was suspected of having a mental illness, intellectual disability or related condition) level one screening and refer one of three sampled residents (Resident 14) who had a diagnosis of schizophrenia (a mental illness that can affect thoughts, mood, and behavior) to the appropriate state-designated authority for PASSR level two evaluation and determination. This deficient practice had the potential to result in Resident 14 not receiving appropriate treatment recommendations for schizophrenia. Cross Reference F641.

Inspectors wroteBased on interview and record review, the facility failed to develop an individualized person-centered plan of care with measurable objectives, timeframe, and interventions to meet the resident's needs for three out of four sampled residents (Residents 19, 24, and 39) by failing to: 1. Address Resident 19's need for a one to one (1:1, close supervision) sitter. This deficient practice had the potential to result in a lack of meeting necessary care goals and addressing medical needs for Resident 19. 2. Develop a care plan for significant weight loss for Resident 24. This deficient practice had the potential to place Resident 24 at risk for further weight loss related to not having nutritional interventions. 3. Ensure a care plan with interventions for swollen ankles was in place for Resident 39. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one out of eight sampled Residents (Resident 47) was taken outside for a garden stroll. This deficient practice of not taking Resident 47 outside for a garden stroll had the potential to negatively affect the resident's mental and emotional well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, by failing to check pacemaker (a small battery-powered device that monitors and regulates the heart's rhythm and rate) for one of one sampled resident (Resident 63). This deficient practice had the potential to result in pacemaker failure possibly leading to medical complications requiring hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate services to decline in joint range of motion (ROM, full movement potential of a joint) for three out of 12 sampled residents (Residents 64, 14, and 15) who had limited ROM or were assessed at risk for decline in joint ROM, as indicated in the resident's care plans. The facility failed to: 1. Ensure Resident 64 received timely quarterly rehabilitation joint mobility screens to monitor changes in joint range of motion. 2. Ensure Resident 14 received timely quarterly rehabilitation joint mobility screens to monitor changes in joint range of motion. 3. Ensure Resident 15 received timely quarterly rehabilitation joint mobility screens to monitor changes in joint range of motion. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. Ensure Resident 81 had floor mats at bedside to prevent injury from a fall. This deficient practice of not placing floor mats at the Resident 81's bedside had the potential for injury if Resident 81 was to have a fall. 2. The sharps container (a puncture-proof container used to contain used and discarded needles and other sharp tools for patient care) in rooms 221, 321 and 333 were replaced with a new one when it was at least 75 percent (%) full. This deficient practice had the potential for staff or resident to sustain an injury with a full sharps container.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure oxygen (air) tubing and humidifier (a device that humidifies oxygen for patients undergoing oxygen therapy) were dated, labeled, and changed every seven days in accordance with facility's policy and procedure for one of five sampled residents (Resident 23). This deficient practice had the potential to cause respiratory infection for residents on oxygen therapy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the physician signed an order for a one to one (1:1, close supervision) sitter for one out of eight sampled residents (Resident 19). This deficient practice had the potential for poor continuity of care and follow-up on the resident's status for each physician visit.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide physical therapy (PT, a rehabilitation profession that restores, maintains, and promotes optimal physical function) services with an active physician's order for one of 12 sampled residents (Resident 64) when no PT services were provided after a physician's order dated 4/9/2024 for PT evaluation and treatment. This deficient practice had the potential for Resident 64 to have a decline in functional mobility without PT services.

Inspectors wroteBased on interview and record review, the facility failed to maintain timely resident medical records for one of twelve sampled residents (Resident 63) when Resident 63's Joint Mobility Assessment (JMA) dated 11/20/2023 was not documented until 10/3/2024. This deficient practice had the potential for inaccurate medical documentation and cause a delay in provision of appropriate interventions for Resident 63.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled resident's (Resident 17) representative (FM 1) understood the facility's arbitration agreement (a document that settles any disputes between two parties through binding arbitration [a dispute resolution outside of the legal court system]). This deficient practice resulted in FM 1 entering into an agreement for binding arbitration without fully understanding what they were signing.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the hospice (compassionate care for people who are near the end of life provided at the person's home or within a health care setting) services meet professional standards for one of two sampled residents (Resident 122) by failing to: 1. Ensure hospice representative participates with facility interdisciplinary team ([IDT] team members from different disciplines who come together to discuss resident care) care conference meeting. 2. Ensure to have a hospice calendar with the scheduled visits for the hospice team. 3. Ensure current physician's certification for hospice benefit (a confirmation that a patient is terminally ill and has a prognosis of six months or less to live) was available in the resident's medical record. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staffing information was updated and posted in a visible and prominent place daily. This deficient practice had the potential for residents, staff, and visitors to be unaware of the accurate number of clinical staff taking care of residents daily.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure head of bed was elevated to 30 to 45 degrees as ordered by the physician, for 1 of 4 sampled residents, Resident 2, while gastrostomy tube feeding [GT] nutrition administered via an surgical openning in the abdomen into the stomach) was ongoing. This failure had the potential to result in aspiration (occurs when food or liquid is breathed into the airways or lungs, instead of being swallowed), difficulty breathing, infections and hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to ensure responsible party for one three residents (Resident 1), was notified of the right wrist and right elbow skin discoloration observed, physician's xray (process of taking pictures of tissues and structures inside the body for diagnosis and treatment) order and the xray result. This failure resulted to the responsible party not aware of the change in condition and intervention ordered by the physician.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure one of three sampled residents (Resident 1) was free from abuse when CNA 1 grabbed Resident 1's wrist. This deficient practice had the potential for Resident 1 to have psychological distress and caused Resident 1 to experience feelings of humiliation and disrespect.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Follow its policy and procedure (P&P), titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated 4/2021 and revised 3/2024, which indicated the facility did not condone any form of resident abuse or neglect for one of three residents (Resident 1). As a result, this violation had the potential to place Resident 1 and other residents at risk of further abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was assessed at risk for falls, did not have a fall, by failing to ensure: 1. Staff implemented Resident 1's physician's order which indicated to apply a soft belt (a device that is placed on a person's waist to prevent them from falling out of a bed or a chair) on Resident 1 when up in a wheelchair for safety. 2. Staff followed Resident 1's care plan titled Restraint: Soft belt while up on wheelchair for safety, which indicated to apply a soft belt on the resident while up on a wheelchair for safety, to prevent falls and injuries. 3. Staff followed the facility's policy and procedure (P&P) titled Soft/ Self Release Belt, which indicated a wheelchair soft self-release belt was to be used on a resident for safety. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete the 72-hour neuro checks (assessment how resident speaks, thinks, walks, moves, or interacts with the examiner) as indicated in the facility's policy and procedure, for 1 of 3 sampled residents, (Resident 1). This failure had the potential to delay interventions if Resident 1 displayed changes in neurological status (a person's mental status, coordination, ability to walk, and how the muscles, sensory systems, and deep tendon reflexes work).

Inspectors wroteBased on interview and record review, the facility staff failed to implement or develop resident-specific communication care plans for one of three sampled residents (Resident 1). This deficient practice created the potential for direct care staff to be unaware of Resident 1's preferred language, and the communication aids necessary to ensure Resident 1's verbalized choices and preferences for care were understood and respected.

Inspectors wroteBased on interview and record review, the facility failed to implement its abuse policy and procedure (P&P) by failing to report an injury unknown origin to the California Department of Public Health (CDPH) within two hours for one out of three sample residents (Resident 1). This deficient practice resulted in a delay in the investigation by the CDPH.

Inspectors wroteBased on interview and record review the facility failed ensure one out of three Residents (Resident 1) was free from falls. This deficient practice of not supervising the safety of Resident 1 placed the resident at risk for a fall.

Inspectors wroteBased on interview and record review, the facility failed to provide supervision (an intervention and a means of mitigating accident risk) during walking and toileting for one of three sampled residents (Resident 1). This deficient practice resulted in Resident 1 falling, sustaining a fracture (broken bone) to the right arm which required hospitalization in a general acute care hospital (GACH) for evaluation and treatment.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to enforce their infection prevention and control program by failing to report to licensing and certification of the coronavirus disease [(COVID-19), a highly contagious viral illness) outbreak. This failure had the potential to cause the spread of the COVID-19 outbreak in the facility and cause other residents to become ill.

Inspectors wroteBased on interview and record review, the facility failed to report to the State Agency (SA) the reports of all investigations regarding staff to resident abuse allegation within five (5) working days, for one of three residents,(Resident 2). This deficient practice resulted in an incomplete investigation and overlooked areas of concern that had the potential to place Resident 2 and other residents at risk for abuse and mistreatment. Findings During a review of Resident 2 ' s admission record (Face sheet), the face sheet indicated Resident 2 was admitted to the facility on [DATE], with a diagnosis including diabetes (high blood sugar), depression (a mood disorder that causes persistent feelings of sadness and loss of interests), and hypertension (high blood pressure). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of three sampled residents, (Resident 2 and Resident 3) were free from falls and injuries, by failing to: 1. Ensure Resident 2, who fell on 7/24/2022, had an accurate post fall risk assessment (an assessment conducted after a fall) to correctly identify and reflect Resident 2's clinical condition, as a high risk for fall. 2. Ensure Resident 2's fall risk care plan was revised to reflect fall safety interventions after Resident 2 fell on 7/24/2022. 3. Ensure Resident 3 had an updated care plan with interventions for safety after Resident 3 fell on [DATE]. Resident 3 had another fall on 11/20/2023, approximately 12 days after the previous fall. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a fall risk care plan, with fall prevention interventions recommended by the interdisciplinary team (IDT, professional disciplines, as appropriate, who work together to provide the greatest benefit to the resident), for one of three sampled residents (Resident 4), following two falls sustained in the facility on 8/9/2023 and 8/27/2023. This failure increased the potential for Resident 4 to suffer from avoidable physical harm from a third fall she sustained in the facility on 1/15/2024.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide adequate supervision for one of 29 sampled residents (Resident 92) by failing to: 1. Ensure Resident 92 had a safe room environment free from potential fire hazard and burns when using a candle maker. Resident 92 ordered a candle maker from a store a year ago. Resident 92 was using the candle maker to make candles and soap and with no supervision. The candle maker had the ability to reach high temperatures ranging from 196 - 315 degrees Fahrenheit (a scale of temperature). 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure four of 18 sampled residents (Residents 92, 134, 26, and 56) had develop a comprehensive and resident-centered care plan 1. Resident 92 did not have a care plan developed to address the use of electric appliances. 2. Resident 134 did not have a care plan developed to address the use of splints (a device to maintain hand in a functional positioning during paralysis recovery) to right hand as ordered by the physician. 3. Resident 26 did not have a care plan developed to address a prophylactic (intended to prevent disease) medication. 4. Resident 56 did not have a care plan developed to address smoking. This deficient practice had the potential to negatively affect the delivery of nursing care and medical interventions to Residents 92, 134, 26, and 56.

Inspectors wroteBased on interview and record review, the facility failed to ensure: 1) Four licensed vocational nurses (LVNs) did not administer expired pantoprazole (medication used to treat acid in the stomach) liquid suspension (mixture in which particles are dispersed throughout the fluid) to one of three residents (Residents 24) observed for medication availability. 2) Nine LVNs did not administer expired ipratropium with albuterol (a combination medication used to treat and prevent shortness of breath) inhalation solution to one of three residents (Residents 87) observed for medication availability. 3) Three LVNs did not administer expired insulin (medication used to regulate blood sugar levels) Basaglar (brand name for insulin) Kwikpen (device used to administer the insulin) to one of three residents (Resident 110) observed for medication availability. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in te kitchen when: 1. Several food items were not dated, labeled, and sealed after opened in the reach in refrigerator, and dry storage area. Cottage cheese labeled with use by date exceeding manufacturer use by date, and raw ground beef stored in fridge with a thaw date of 9/19/23 for 7 days exceeding facility policy for storing raw ground beef. 2. Dry individually packed cereal boxes were stored inside large, corrugated packaging boxes in the dry food storage room. 3. The can opener blade was worn and nicked with the potential to harbor harmful bacteria that were not easily cleanable. 4. One dietary staff working in the dish machine area did not was hands when removing the clean and sanitized dishes from the dish machine. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the trash stored in the dumpster area was maintained in a sanitary manner. six out of six garbage bins were uncovered and lids open, 1 out of two red biohazard bin was overfilled and lid open, there was trash milk carton and red sauce like ketchup scattered on the floor. This deficient practice had the potential for harborage and feeding of pests.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Follow their policy for monitoring temperature for three of three washing machines (washing machine 1, 2, and 3) and four of four clothes dryers (dryers 1, 2, 3, and 4). 2. Document the temperature for three of three washing machines (washing machine 1, 2, and 3) and four of four clothes dryers (dryers 1, 2, 3, and 4). These deficient practices had the potential to result in spread of infection (the invasion and growth of germs in the body) throughout the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide accurate information in the Minimum Data Set (MDS), a standardized assessment and care screening tool) for two of two sampled Residents (Resident 67 and 138). This deficient practice had the potential to result inaccurate care and services for the residents due to inappropriate MDS care screening and assessment tool practices.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of 18 sampled residents (Residents 56 and 118), change of condition PASRR was submitted for review to the Department of Health Care Services (DHCS). 1. Resident 56's level one PASRR was not resubmitted after a change of condition to ensure the resident was re-evaluated for biploar disorder. 2. Resident 118's level one PASRR was not resubmitted after a change of coniditon on 5/18/2023 to include depressive disorder with psychotic symptoms. This failure placed the residens at risk for not receiving appropriate care and services to address the resident's needs.

Inspectors wroteBased on observation, interview, and record review one out of 29 sampled residents (Resident 92) the facility failed to ensure Resident 92 had a revised Care Plan and Intradisciplinary Team (IDT) Meeting with efficient interventions to address the hoarding. This deficient practice of not developing a revised care plan with efficient interventions placed Resident 92 at risk for safety hazards.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Indicate an updated physician's order on the medication bubble pack (a medication packaging system that contains individual doses of medication per bubble) for one of four sampled residents for medication administration (Resident 139.) 2.administer medication as ordered by the physician for one of four sampled residents for medication administration (Resident 139.) 3.transcribe (write or type) the physician medication order in the clinical chart for one of four sampled residents for medication administration (Resident 139.) 4.include the verifying signatures of either the Director of Nursing (DON) or a Registered Nurse (RN) along with a licensed vocation nurse (LVN) on the Controlled (also known as Controlled Substance [CS]- medications which have a potential for abuse and may also lead to physical or [...]

Inspectors wroteBased on interview and record review the Administrator failed to conduct proper oversight over the facility's safety hazards to ensure one out of 29 sampled residents (Resident 92) was monitored by staff before using a candle maker with wax that could reach a temperature of 315 degrees Fahrenheit. This deficient practice increased the risk for Resident 92 to suffer potential burns from using a candle maker with wax.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify and address one of 29 residents' (Resident 92) unsafe room condition that was cluttered and had an electric operated candle maker in the room, at the facility's Quality Assessment and Assurance committee [QAA, a committee required to meet at least quarterly to identify issues and to develop and implement plans of action to correct identified deficiencies and to coordinate and evaluate activities under the QAPI (Quality Assurance, Performance Improvement) program, to include performance improvement projects] meetings. This failure placed the affected resident, all other residents, and staffs at a higher risk for serious harm and injuries and had the potential for insect infestations in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 29 sampled residents, (Resident 92) was provided a safe and comfortable environment by failing to ensure Resident 92 was monitored and supervised for safety during the use of the electric operated candle maker in the room when making candles and the resident's room refrigerator was monitored for expired food. These failures placed Resident 92 at risk for serious harm and injuries, and the potential for food borne illnesses.