Studebaker Healthcare Center

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident (Resident 2) who was assessed as a high fall risk, had a history of falls, and an inability to communicate his needs, staff implemented interventions timely and developed a Care Plan addressing his inability to communicate his needs for one of three sampled residents (Resident 2). These failures resulted in Resident 2 falling on 2/11/2026 and 2/12/2026, and placed Resident 2 to at risk for serious injuries, including head, back, hip, or neck injuries, fractures (a break in the bone), internal brain bleed (a life-threatening condition that occurs when a blood vessel in the brain bursts or leaks blood), or death.

Inspectors wroteBased on interview and record review, the facility failed to ensure the attending physician (AP) 1 performed and documented an initial physical assessment for a resident (Resident 1) who was newly admitted to the facility for one of three sampled residents (Resident 1). This deficient practice resulted in AP 1's failure to identify, assess, and document Resident 1's condition and/or well-being. This deficient practice had the potential for an undetected decline in Resident 1's medical, health, or psychosocial status and a delay in the initiation of appropriate care, treatment, and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure Certified Nursing Assistant (CNA) 5 accurately documented activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily) for one of six sampled residents (Resident 1). This failure resulted in an inability to determine the care and services provided to Resident 1 and had the potential for delayed or unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the nursing staff had appropriate competencies and skill set to provide 94 out of 94 residents with care and services when:94 out of 94 licensed nursing staff were not in-serviced, and competency was not validated in the provision of Cardiopulmonary Resuscitation ([CPR] emergency lifesaving procedure when the heart stops beating) and emergency services for residents who are unresponsive. One of four nursing staff (Licensed Vocational Nurse (LVN) 4) did not have a performance evaluation (process organizations follow to assess an employee's work quality and skills over a specific period) in 2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medical records for 5 of 14 sampled residents (Residents 3, 15, 37, 4, and 101) records were accurate, complete and readily accessible by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 1 did not document Resident 15's bismuth subsalicylate (a medication used to treat diarrhea, nausea, heartburn, indigestion and gas) oral suspension as administered on Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) when bismuth subsalicylate was not available in stock and was not administered on 2/18/2026.2. Document Resident 3's intravenous ([IV] into the vein) administration of cefepime (an antibiotic administered intravenously or intramuscularly to treat severe bacterial infections) as administered on MAR.3. [...]

Inspectors wroteBased on interview and record review the facility's Quality Assessment and Assurance (QAA) Committee, affecting 94 out of 94 residents, failed to identify and implement corrective action to the systemic problems identified: Ninety-four (94) out of 94 licensed nursing staff were not in-serviced, and competency was not validated in the provision of Cardiopulmonary Resuscitation ([CPR] emergency lifesaving procedure when the heart stops beating) and emergency services for residents who are unresponsive. Three out of three Restorative Nursing Aides (RNA, trained nursing staff who help residents gain an improved quality of life by increasing their level of strength and mobility) were not in-service and competency was not validated at least annually on skill set needed to function as RNAs. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure two of three sampled resident's or their legal representatives' (Resident 78 and 106) informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for psychotropics (drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) was obtained prior to administration of medications and before Resident 106's restraint (measure aimed at controlling a residents' physical movement that cannot be easily removed by the resident him/herself) were used. use. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure three of three sampled residents (Resident 52, Resident 67, and Resident 89) had their call lights (device that residents press to request staff assistance when needed) within reach. 2. Ensure the mobility needs of one of seven residents (Resident 84) were accommodated by not providing an appropriately sized wheelchair since the resident's admission in October 2025. This failure resulted in Resident 84's mobility needs not being met and placed the resident at risk for discomfort, loss of independence, and had the potential to place the residents at risk by limiting their ability to request assistance in a timely manner, delayed response to needs, and increased risk for falls or injuries.

Inspectors wroteBased on interview and record review, the facility failed to:1. Develop and implement a comprehensive care plan to address Resident 101's risk for dehydration (low level of fluids in the body).2. Develop and implement a comprehensive care plan for Resident 101's diuretic (medication used to remove excess salt and water from the body) use and monitoring.3. Develop and implement a comprehensive care plan to address refusals to participate in Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) and Restorative Nursing Aide (nursing aide program that help residents maintain any progress made after therapy intervention to maintain their function) programs for Resident 34 who was identified as having range of motion (ROM, full movement potential of a joint) and mobility (ability to move) concerns.4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for 3 of 10 sampled residents (Residents 3, 42, 101) by failing to:1. Follow up with an orthopedic (specialty area in medicine referring to the management of the muscles, bones, and their connective structures) consultation appointment for Resident 3's left humerus (upper arm bone) fracture (broken bone) per consulting physician's recommendations.2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services to improve or maintain range of motion (ROM, full movement potential of a joint) for three of seven sampled residents (Residents 3, 4, and 42) with ROM concerns by failing to: 1. Assess Resident 3's left shoulder and left-hand range of motion (ROM, full movement potential of a joint) during the Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) Evaluation, dated 11/13/2025, and the Joint Mobility Assessment (JMA, a brief assessment of a resident's ROM in both arms and both legs), dated 1/10/2026. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to:Notify the physician when Resident 101 had less than 50 percent (%) oral intake Notify the physician when Resident 101 experienced a 10lb weight loss in 1 week on 11/26/2025. Follow the facility policy to conduct interdisciplinary team (IDT) on Weight Variance for Resident 101 These deficient practices resulted in incomplete and unclear weight and nutrition status and had the potential to delay delivery of care and timely interventions to prevent further weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5% (percent) during medication pass for two of five sampled residents (Residents 95 and 15) by failing to:1. Ensure Resident 95's carvedilol's (a medication used to treat high blood pressure) hold parameters regarding blood pressure were clarified with a physician.2a. Ensure Resident 15's bismuth subsalicylate (a medication used to treat diarrhea, bloating and abdominal discomfort) was available in stock to administer to Resident 15.2b. Clarify Resident 15's diclofenac gel's (a medication used topically to relieve pain and inflammation) dose and/or amount to be applied before applying it on the resident's lower back. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to:1. Ensure the Emergency Kit ([E-Kit] emergency drugs supply) in one of one inspected medication rooms (Station 2 Medication Room) containing controlled (prescribed medication that carries a risk of misuse, abuse, or dependence) and noncontrolled medications was sealed and locked. 2a and 2b. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure to store food in a safe and sanitary manner to prevent growth of microorganisms that could cause foodborne illness (food poisoning: any illness resulting from the food spoilage of contaminated food, pathogenic bacteria, and viruses for 94 out of the 98 residents in the facility by failing to: Ensure the facility failed to date and label produce and storage goods. Ensure the facility failed to discard expired food items in the dry storage. These deficient practices had the potential to result in pathogen (germ) exposure to residents and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea and fever and can lead to other serious medical complications and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility and/or facility licensed nurse failed to follow infection control and prevention procedures by failing to:1. Wear personal protective equipment ([PPE] - specialized clothing designed to protect workers from injury, illness, and infection) before entering Resident 15's room that required Enhanced Barrier Precautions ([EBP] - infection control measures in nursing homes, requiring gown and glove use during high-contact care for residents with chronic wounds, indwelling devices, or known MDRO colonization, aiming to reduce multidrug-resistant organism (MDRO) transmission) and before administering and/or applying medications for Resident 15.2. Wash hands after going through trash and before applying diclofenac gel (a topical medication used to treat inflammation and pain) on Resident 15's lower back.3. [...]

Inspectors wroteBased on interview, and record review, the facility failed to implement their Antibiotic Stewardship Program (a plan to promote the appropriate use of medication to fight infection) when two of three sampled residents (Resident 101 and Resident 121) received antibiotics without meeting McGeer Criteria (set of guidelines used by medical staff to determine if a person has an infection). This failure had the potential to place Resident 101 and Resident 121 at risk for receiving unnecessary antibiotics, which can lead to adverse effects such as antibiotic resistance, side effects, and complications related to inappropriate use.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 101) and resident representative (RP) consented to and were educated on the risks and benefits of the influenza (flu- a respiratory infection that affects the nose, throat, and lungs) vaccine prior to administration. This failure had the potential to result in an increased risk of adverse reactions or complications to the flu vaccine due to undisclosed allergies, medical conditions, or contraindications.

Inspectors wroteBased on interview and record review, the facility failed to provide documented evidence of COVID-19 (a contagious respiratory disease that spreads from person to person through coughing, sneezing, or talking) vaccine screening, education, administration, and/or declination for two of four sampled staff members Medical Director (MD) 1 and Pharmacist (PH). This failure had the potential for increased risk of COVID-19 exposure to staff and residents from delayed identification of vaccine status and missed opportunities to prevent the spread of COVID-19 within the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a safe and functional environment by failing to:Ensure two out of four sampled residents' (Resident 42 and 82) bathroom sink was clogged. Ensure one out of two showers (Shower 1) water temperatures did not fluctuate (be irregular). These deficient practices had the potential to result in creating a hazardous environment which could result in residents' injury and discomfort.

Inspectors wroteBased on observation, interview and record review, the facility failed to accommodate husband's and wife's (Resident 89 and Resident 90) wish to live together in the same room. This deficient practice resulted in (or had potential to cause) moral distress for both residents as well as to other residents because Resident 89, is searching for Resident 90, wandering from room to room, which caused disturbance to other residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled residents (Resident 8's) medical information was kept private from unintended public view. This deficient practice had the potential to result in a breach of Resident 8's health care information, privacy and confidentiality.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of five sampled residents (Resident 106) was free from physical restraint by placing an abdominal binder (a wide, stretchy belt that wraps around the stomach area) on the resident without an order, informed consent from the family member, or an assessment indicating the need for the abdominal binder. These deficient practices had the potential to result in injury and inhibit the residents' freedom of movement or activity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of seven sampled residents (Resident 3) who had communication difficulties was provided access to a communication aid (tool designed to assist persons with speech and language difficulties in expressing their needs and understanding to others) and/or alternative communication strategies to facilitate communication with residents and staff. This deficient practice had the potential to prevent Resident 3 from communicating his needs, resulting in frustration, isolation, and delay in care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the G-tube feeding (a way of providing essential nutrients, fluids, and medications when a person cannot eat or drink by mouth) formula was labeled with a start date and time for one of three sampled residents (Resident 72). This failure had the potential to place the resident at risk of receiving expired tube formula, which could compromise nutritional status, increase the likelihood of illness or infection, and result in avoidable adverse outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 37) received respiratory care as ordered by the physician when:a. The resident did not receive the prescribed oxygen concentration (the percentage of oxygen delivered through an oxygen device) as ordered by the physician.b. The resident's oxygen humidifier bottle (container filled with water that adds moisture to the dry oxygen before it is breathed in) was not changed in accordance with the physician's order and facility policy. This failure had the potential to place the resident at risk of harm, including complications related to receiving oxygen at a higher flow rate than ordered and adverse effects associated with the use of an outdated humidifier bottle.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two Certified Nurse Assistants (Restorative Nurse Assistant 1 [RNA 1]) had an annual performance evaluation (process organizations follow to assess an employee's work quality and skills over a specific period) from 2022 to 2025. This failure had the potential to result in the provision of inadequate care and services to residents to help them attain highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to:1. Ensure one of two inspected medication carts (Station 2 Medication Cart) maintained accurate documentation of Resident 74's hydrocodone-acetaminophen (a controlled medication [medications that the use and possession of are controlled by the federal government] in combination with acetaminophen [APAP - a medication used to treat pain] used to treat severe pain) on accountability record or controlled medication count sheet/controlled drug record ([CDR] - a document indicating perpetual inventory and administration of controlled substances after the hydrocodone-APAP was administered, as per facility's policy and procedure (P&P) titled, Controlled Medications, dated 10/1/2023.2. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow the consultant pharmacist's (a professional responsible for reviewing each resident's medication profile monthly to identify and report changes) recommendation for one of five residents reviewed for unnecessary medications, dated 1/12/2026 to consider an alternative option to Resident 3's tramadol (a controlled medication [medications that the use and possession of are controlled by the federal government] used to treat moderate to severe pain) for pain management and to discontinue tramadol because tramadol could lower Resident 3's seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) threshold. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent a significant medication error for one out of five (Resident 95) sampled residents during medication administration, by failing to clarify hold parameters for Resident 95's carvedilol (a medication used to treat high blood pressure) with a physician before deciding whether to administer or hold the medication. This deficient practice failed to ensure Resident 95's carvedilol was administered in accordance with physician's orders or professional standards of practice and had the potential to result in high blood pressure and/or low blood pressure, cardiovascular complications and hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician of abnormal lab values on 12/16/2025 for one of three sampled residents (Resident 101). This had the potential to result in delayed care or interventions for Resident 101.

Inspectors wroteBased on observation, interview and record review, the facility failed to honor dietary preferences for one of five sampled residents (Resident 21) when Resident 21 received eggs despite the resident's documented dislike for eggs. This placed Resident 21 at risk of not eating and decreased nutritional intake.

Inspectors wroteBased on interview and record review, the facility failed to protect one of three sampled residents (Resident 1) right to be free from verbal abuse when Certified Nurse Assistant (CNA) 1 cursed (used foul language) in front of Resident 1 while providing care. This deficient practice placed Resident 1 at risk for psychological harm, loss of dignity and feeling uncomfortable and had the potential to result in further abuse for Resident 1 and all residents in the facility.

Inspectors wroteF609Based on interview and record review, the facility failed to report an abuse allegation to the California Department of Public Health (CDPH), for one of three sampled residents (Resident 2), when Resident 2 reported to the Director of Staff Development (DSD) that Certified Nurse Assistant (CNA) 2 made a sexually inappropriate gesture while providing him with personal care. This deficient practice placed Resident 2 at risk of embarrassment and anger and had the potential to place Resident 2 and all other residents at risk in the facility for sexual abuse.

Inspectors wroteBased on interview and record review, the facility failed to implement its abuse policy and procedure (P&P) titled, Abuse Prevention and Prohibition Program by failing to investigate an allegation of sexual abuse for one of three sampled residents (Resident 2). This deficient practice had the potential to result in unidentified abuse in the facility and failure to protect all residents in the facility from abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure abnormal laboratory (lab) results, provided to the facility on 9/9/2025, for one of three sampled residents (Resident 1) were reported to Resident 1's physician in a timely manner and a response from the physician with instructions for care was obtained. This deficient practice resulted in Resident 1's physician not being made aware of Resident 1's abnormal lab results when they were reported to the facility on 9/9/2025, until 9/10/2025, and a delay in transferring Resident 1 to the GACH (9/10/2025). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 1 documented one of three sampled residents (Resident 1) laboratory (lab) results and communication of those lab results in Resident 1's medical record. This deficient practice resulted in an incomplete/inaccurate depiction of Resident 1's general well-being and had the potential for non-continuity of care.

Inspectors wroteBased on interview and record review, the facility failed to provide the results of multiple grievances filed by one of three sampled resident's (Resident 1) and/or their responsible party (RP). This deficient practice resulted in Resident 1 and/or his RP not being aware of the outcome/resolution of the grievances filed by him and his RP, which led to distrust toward the facility. This deficient practice had the potential to delay the delivery of care and services to Resident 1 and could negatively impact Resident 1's mental health and emotional well-being.

Inspectors wroteCross referenced to F713Based on interview and record review the facility failed to follow up with the physician and/or the Medical Director for one of three sampled resident's (Resident 1), when Resident 1's physician did not respond to a text message sent to him on 8/20/2025 regarding Resident 1's change of condition (COC). In addition the facility failed to ensure Resident 1's complete COC was relayed to his physician via the text messages and documentation of the interaction with the physician, to include, the time of the text message, method of communication and endorsement to other staff, was completed. [...]

Inspectors wroteCross referenced to F580Based on interview and record review, the facility failed to ensure a physician responded to one of three sampled resident's (Resident 1) change of condition in a timely manner when Resident 1's physician (MD 1) did not respond to Licensed Vocational Nurse (LVN 1) text messages on 8/20/2025 for greater than eight hours. This deficient practice resulted in Resident 1 experiencing increased anxiety (persistent an excessive worry which interferes with daily activities) and potential delay in needed care and services, including transfer to the General Acute Care Hospital (GACH).

Inspectors wroteBased on interview and record review the facility failed to ensure one of three sampled residents (Resident 1) was treated with respect and in a dignified manner. The facility failed to: 1. Ensure Resident 1 ' s was treated with dignity and respect when the Certified Nurse Assistant (CNA) 1 removed Resident 1 ' s glasses from his hands without his permission when turning Resident 1 to his side while he was lying in bed. 2. Ensure Resident 1 ' s rights were upheld when the facility did not provide Resident 1 with an admission packet, which provided the resident ' s bill of rights and policies and procedures pertaining to the facility. These deficient practices resulted in: 1. Resident 1 ' s feeling violated by CNA 1 and not wanting further interaction with CNA 1. 2. Resident 1 being unaware of his rights, policies and procedures of the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was diagnosed with amyotrophic lateral sclerosis ([ALS]progressive disease that affects nerve cells in the brain and spinal cord, leading to the weakness, paralysis and death), was injured, when he was hit on his head by the mechanical lift (mechanical device used by caregivers to safely transfer patients) lift upon transfer from his bed to the wheelchair. As a result of this deficient practice, Resident 1 required transfer via 911 to a General Acute Care Hospital for evaluation and treatment and was found to have a head and chest contusion (bruise).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident (Resident 1), who was alert, continent (ability to control) of bowel and bladder, and had a high risk for a pressure ulcer/injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) development, received care and services to maintain bowel and bladder function for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure the nursing staff assisted Resident 1 timely to use the urinal to maintain the resident's bladder continence (the ability to voluntarily control emptying the bladder). 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately document the medications administered to one of three sampled residents (Resident 1), when Resident 1 refused to receive medications from Licensed Vocational Nurse (LVN) 1 on 5/2/2025 at 9 p.m. This deficient practice resulted in inaccurate documentation on Resident 1 ' s Medication Administration Record (MAR] a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) when the Licensed Vocational Nurses (LVNs 1 and 2) administered Resident 1 ' s 9 p.m. medications on 5/2/2025.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility had safe guards in place for their controlled drugs (a drug or other substance that is tightly controlled by the government because it may be abused or cause addiction) to prevent loss of and/or diversion (the illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber) of controlled drugs in the facility for two of three sampled residents (Residents 1 and 2), by failing to: 1. [...]

Inspectors wroteBased on observation and interview, the facility failed to store, handle, and maintain food/food supplies with professional standard for food service safety as evidenced by failing to: 1. Ensure to store food with label and open date. 2. Ensure to label five sack lunches for resident's who go out the facility for dialysis (mechanical removal of waste from the blood for residents with end stage kidney disease) with dates the sack lunches were prepared. 3. Ensure the commercial can opener was free from a black sticky substance on the blade and the base of the can opener. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two of five sampled residents (Resident 89 and Resident 2) had a completed advance directive (a written statement of a person's wishes regarding medical treatment) acknowledgement and Physician Orders for Life-Sustaining Treatment ([POLST]- a medical order that helps give people with serious illness more control over their care during a medical emergency) in their medical records as evidenced by: A. Failing to ensure follow-through with the regional center to obtain the completed advance directives form and have a current copy of the advance directive in Resident 89's medical record. B. Failing to ensure Resident 2 or his/her representative had the opportunity to formulate an advance directive. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement a comprehensive care plan for two of four sampled residents (Resident 2 and Resident 50) by failing to ensure: 1. Resident 2 had a comprehensive care plan for a person with an intellectual/developmental disability ([IDD], a group of conditions that impact a person's intellectual, physical, and emotional development). 2. Resident 50 had a comprehensive care plan for a person that wears a bipap (help push air into your lungs, supplies pressurized air into your airways by helping open your lungs with pressured air at night) machine. This deficient practice had the potential to negatively affect the quality of life and wellbeing for Resident 2 and Resident 50 and to prevent them from achieving their highest practical well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of eight sampled residents (Resident 71) who received required hemodialysis (HD-a treatment to cleanse the blood of wastes and extra fluids artificially though a machine when the kidney(s) have failed) services was provided adequate care by not: a. Updating Resident 71's medical records for hemodialysis schedule since 9/5/2024, when the order was changed by the hemodialysis center. b. Documenting Resident 71's refusal to go to HD, follow up appointment and notifying the medical doctor (MD). c. Reporting out of range Hemoglobin (Hgb) A1C (a test that indicates the average level of blood sugar control over the last couple of months) to the MD on 4/19/2024 and 11/21/2024. d. Providing Resident 71 snacks while out of the facility on hemodialysis days. [...]

Inspectors wroteBased on interview and record review the facility failed to administer prescription medications as ordered for two out of two residents (Resident 20 and 75) in November 2024. The deficient practices had the potential to result in poor physical and psychological outcomes.

Inspectors wroteBased on interview and record review the facility failed to develop nonpharmacological measures to address combative behavior for two out of two residents (Resident 20 and 75) who were on an as needed (PRN) use of psychotropics (medications that alter perception, mood, consciousness, cognition --ability to think, or behavior). The deficient practice had the potential to result in use of unnecessary medications placing Resident 20 and Resident 75 at risk of medication side effects.

Inspectors wroteBased on observation, interview and record review, the facility failed to administer medications appropriately for two out of four residents (Residents 9 and 16) as observed during the medication pass. During medication pass, there were five medication errors for Resident 16, and one medication error for Resident 9 for a total of 6 medication errors out of 26 opportunities. These medication administration errors resulted in a medication error rate of 23.08%.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure bubble pack (medication dispensed by the pharmacy in a single use dose compartments) medications were labeled with parameters (guidelines to assess the resident for before administering the medication) for two of two sampled residents (Resident 16 and 9) 2. Ensure Insulin (medication to regulate blood sugar levels) vials were labeled with the date it was opened. 3. Ensure saline (saltwater) solution was stored in a secured location inaccessible to unauthorized persons. 4. Ensure Vitamin K (vitamin needed for blot to clot) in the emergency kit (receptacle contains medications that can be dispensed when pharmacy services are not available) was not expired. These deficient practices had the potential to result in medication errors.

Inspectors wroteBased on observation, interview, and record review the facility failed to: a. Ensure Licensed Vocational Nurse (LVN) 1 donned (put on) an isolation gown while administering medications through the Gastrostomy tube (G-tube - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) for one of one resident (Resident 19). b. Ensure Certified Nurse Assistant (CNA) 4 performed hand hygiene and wore personal protective equipment (PPE) when providing care for one of two residents (Resident 81) reviewed for G-tubes. c. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff treated each resident with respect and dignity during assistance with feeding for one of 11 sampled residents (Resident 89) by failing to sit next to Resident 89 at eye level and feed her without rushing her through the meal. This failure had the potential to result in feelings of decreased self-esteem and self-worth for Resident 89.

Inspectors wroteBased on interview and record review, the facility failed to assess mental capacity before providing information for signing Notice of Medicare Non-Coverage (NOMNC- a notice that indicates when the care is set to end from skilled nursing facility. It includes information for how to appeal the provider's decision.) and Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN- a notice that lists the items or services that your doctor or health care provider expects Medicare will not pay for, along with an estimate of the costs for the items and services and the reasons why Medicare may not pay) for one of three sampled residents (Resident 13) and the responsible party. This failure had the potential to result in Resident 13 and responsible party not being able to exercise their right to file an appeal.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their admission process by not itemizing one of three sampled resident's (Resident 71), personal belongings upon admission, and not returning the resident's clothing after being processed from the laundry. This failure resulted in Resident 71's unaccounted for and lost belongings.

Inspectors wroteCross reference F744 Based on interview and record review the facility did not protect two of three sampled resident (Resident 20 and 75) from abuse when the facility failed to: 1) Ensure Resident 75, who had a history of aggressive behavior, did not aggressively approach Resident 20, who also had a history of aggressive behavior. 2) Ensure Resident 75 was close to the nursing station as indicated in the care plan intervention, initiated 11/2/2024, to ensure closer monitoring of Resident 75 for aggression manifested by hitting staff. As a result of the deficient practices, Residents 75 and 20 had a physical altercation in Resident 20's room and Resident 75 sustained scratches on the face.

Inspectors wroteBased on interview and record review, the facility failed to document a transfer form for one of two sampled residents (Resident 47) when resident got transferred to the general acute care hospital ([GACH, to a medical facility that provides short-term, active treatment for a wide range of sudden and severe illnesses or injuries) for vomiting (involuntary expulsion of stomach contents through the mouth or nose). This deficient practice had the potential to delay care due to inadequate information from the sending facility. [...]

Inspectors wroteCross Reference F600 Based on observation, interview, and record review the facility failed to implement the dementia (a progressive state of decline in mental abilities) care plan for two of three sampled residents (Resident 20 and 75). The facility failed to: a) Ensure Resident 75's, who had a history of aggression and resident to resident altercation, room was close to the nursing station and monitored closely to protect safety of others. b) Ensure Resident 20, who had a history of aggression since 6/27/2023, did not scratch Resident 75's face. c)Ensure Resident 75 did not aggressively approach Resident 20 while Resident 20 was in bed and engage in a physical altercation with Resident 20. d) Ensure Resident 75 received all scheduled doses of Memantine (medication for dementia). There were three missed doses in October 2024. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three residents (Resident 71) pharmacy recommendation to repeat the Resident 71's Hemoglobin A1C (Hgb-a test that indicates the average level of blood sugar control over the last couple of months) was followed through with the medical doctor (MD). This failure resulted in Resident 71's repeat Hgb A1c not being ordered, placing Resident 71 at risk for having continued high blood sugar and diabetes complications such as heart disease and stroke.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident who was transferred to a General Acute Care Hospital (GACH) on 12/9/2024 due to the resident's combative behavior after he was found with drug paraphernalia (any equipment that is used to produce, conceal, and consume illicit drugs), was readmitted to the facility on ce the resident was treated and cleared by the GACH to return to the facility on [DATE] for one of three sampled residents (Resident 1). This deficient practice resulted in the denial of Resident 1's bed hold (a resident's right to keep a bed vacant and available for seven days after their transfer to the hospital in anticipation of their return to the facility) and him remaining at the GACH for two days after the GACH deemed Resident 1 able to return to the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one out of three sampled residents (Resident 1) was free from neglect (is defined as failure to provide goods and services as necessary to avoid physical harm, mental anguish. or mental illness), when Certified Nurse Assistant (CNA) 1 left Resident 1 with soiled incontinence briefs for over 2 hours. This deficient practice had the potential for Resident 1 to feel no one cares, neglected and develop pressure injuries.

Inspectors wroteBased on interview and record review the facility failed ensure: a) One of two sampled residents (Resident 1) had a medical diagnosis indicated for Depakote (medication used to treat mental illness) use. b) One of two sampled resident ' s (Resident 2) PRN (given as needed or requested) psychotropic (drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) medications had the following: i. a specified duration, ii. nonpharmacological (any healthcare intervention that doesn't primarily use medication) interventions prior to use of PRN psychotropic, iii. monitoring for side effects (effect of a drug that is in addition to or beyond its desired effect) and adverse reactions of psychotropics, iv. monitoring for hours of sleep, and v. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure medications, Ciprofloxacin hydrochlorothiazide (HCL) (a medication used to treatment bacterial infections), Mupirocin 2% ointment (a medication used to treat skin infections caused by bacteria), Triamcinolone 0.1% cream (a medication used to relieve redness, itching, swelling or other discomfort caused by skin conditions), Hibiclens 4% foam (a skin cleanser which helps reduce bacteria), and Ammonium Lactate 12% topical cream (a skin cream that treats dry skin) prescribed following dermatology visits on 9/20/2024 and 10/18/2024, and delivered to the facility on the same dates, were administered as ordered to one of three sampled residents (Resident 2) to treat Resident 2's statis dermatitis (a skin condition that occurs when blood pools in the veins of the lower legs, causing skin changes due to poor circulation). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident, who lacked the capacity to make decisions and was conserved, was supervised, and monitored to prevent one of three sampled residents (Resident 1) from eloping (leaving a secured institution without notice or permission) from the facility. Resident 1 was last seen in the facility on 10/10/2024 at approximately 6:54 p.m. in his room. Resident 1 was noted missing on 10/10/2024 at approximately 7:57 p.m. Resident 1's Responsible Party (RP) informed the facility that she knew Resident 1's whereabouts at approximately 9 a.m., on 10/11/2024 This deficient practice resulted in Resident 1's eloping from the facility on 10/10/2024 and his whereabouts being unknown for approximately 14 hours. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one sampled resident (Resident 1) who was discharged from the facility, against medical advice ([AMA] a patient who leaves a medical facility before the physician recommends discharge) on 10/11/2024, and was no longer under the care of a physician at the facility, did not have a procedure performed on 10/14/2024 to remove a gastrostomy tube ([GT] a surgical opening fitted with a device to allow nutrition and medication to be administered directly to the stomach common for people with swallowing problems) in the Director of Nurses (DON) office. This deficient practice resulted in Resident 1 undergoing a procedure at a facility where he no longer resided and where he had no assigned physician or orders/instruction for care. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the consultation notes for an outside of the facility dermatology visit were readily available in the medical record for one of three residents (Resident 2). This deficient practice resulted in the delayed treatment of Resident 2's statis dermatitis (a skin condition that occurs when blood pools in the veins of the lower legs, causing skin changes due to poor circulation), administration of Ammonium Lactate 12% topical cream (a skin cream that treats dry skin), and non-continuity of care. This deficient practice had the potential for Resident 2's skin condition to not heal and/or worsen. [...]

Inspectors wroteBased on interview and record review, the facility failed to initiate a Change of Condition form (COC: a change in a resident ' s health) and get physican's orders to implement infection prevention measures (a set of precautions used to prevent the spread of infectious diseases caused by bacteria or viruses that can be transmitted through direct or indirect contact) for one of four sampled residents (Resident 1) when the facility was informed on 7/15/2024 that Resident 1 had tested positive for Candida Auris (C-Auris: multidrug-resistant fungal infection that can cause serious illness). This deficient practice placed other residents and facility staff at risk for getting infected. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a homelike environment for residents due to eight missing shower tiles and two cracked tiles in one of two shower rooms (shower room [ROOM NUMBER]). This deficient practice placed the residents at risk of cross contamination, spread of disease-causing organisms, and accident/incidents.

Inspectors wroteBased on interview and record review, the facility failed to implement the facility's policy to provide an Interdisciplinary Team Meeting (IDT- a group of professional and direct care staff that have primary responsibility for the development of a plan of care for an individual receiving services) for four of four sampled residents (Resident 1, 2, 3 and 4) when Resident 1, 2, 3, and 4 had physician orders to go out on pass for therapeutic purposes. This deficient practice violated Resident 1, 2, 3, and 4's right or the resident representatives' right to participate in the development of the plan of care. Findings During a review of Resident 1's admission Record, the record indicated Resident 1 was admitted on [DATE] with the diagnosis including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). [...]

Inspectors wroteBased on interview and record review the facility failed to contact and inform the physician to clarify post operative (period after the procedure) orders for one of one resident (Resident 1) after Resident 1 returned from cataract surgery (a procedure to remove the lens of the eye and, in most cases, replace it with an artificial lens) on 4/25/2024. This deficient practice resulted in Resident 1 not receiving Cyologyl Ophthalmic solution 1% (eye drops to dilate eyes), Phenylephrine HCL Ophthalmic solution (medication to dilate eyes), and Tropicamide Ophthalmic solution 1% (eye drops) for four days. Not receiving the prescribed medications had the potential to result in negative health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their infection control practices for one of two sampled residents (Resident 1) who was on contact isolation (precautions taken for residents with contagious germs that are spread through direct and indirect contact) when: a. Certified Nursing Assistant 1 (CNA1) failed to wear gloves while feeding Resident 1. b. Licensed Vocational Nurse 1 (LVN1) failed to remove her personal protective equipment (PPE, equipment worn to minimize exposure to a variety of hazards like gloves, gowns, and face masks) prior to exiting Resident 1 ' s room. These deficient practices have the potential to spread infections throughout the facility and placing other residents, staff, and visitors at risk.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of five sampled residents (Resident 2) who was experiencing pain. This deficient practice placed Resident 2 at risk for unrelieved pain.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident, who was at a moderate risk for elopement, did not elope from the facility for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure licensed nurses assessed Resident 1 to determine his risk for wandering and elopement upon admission to the facility (12/28/2023). 2. Ensure a care plan was developed with interventions to prevent Resident 1 from further attempts to leave the facility immediately following Resident 1's attempt to leave the facility on 1/12/2024. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the responsible party (RP) for one of three sampled residents (Resident 1), after Resident 1 eloped from the facility. This deficient practice resulted in Resident 1's RP not knowing that Resident 1 was no longer at the facility.

Inspectors wroteBased on interview and record review, the facility failed to develop and/or implement a care plan for one of three sampled residents (Resident 1) who had a previous history of elopement (leaving an institution without notice or permission) upon admission. This deficient practice resulted in Resident 1 eloping from the facility with the potential of being exposed to severe environmental conditions including excessive cold, possible motor vehicle accident, medical complications including malnutrition (health problems that may arise due to lack of nutrients [substances found in food necessary for the body to function normally]), dehydration (abnormally low fluid levels in the body), stroke (injury to brain tissue caused by hypertension [abnormally high blood pressure] ) due to missing routine medications including high blood pressure medication, and mood stabilizer medication. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to: a. Ensure staff kitchen personnel were not eating their food in the kitchen. b. Ensure blankets were not placed on the kitchen's floor, counter and on top of the trash can. c. Ensure open food items are dated and labeled in the refrigerator. d. Ensure the Cooks performed handwashing before preparing, cooking, and serving food. e. Ensure dishwashing's temperature was maintained at the proper temperature. These failures had the potential to place residents at risk for food-borne illnesses (any illness resulting from ingestion of food contaminated with bacteria, viruses, or parasites).

Inspectors wroteBased on interview and record review the facility's Quality Assessment and Assurance (QAA a group consisting of the Medical Director, and various department heads that assess and implement improvement measure to systemic issues) Committee, failed to implement corrective action to the systemic problems identified: 1. Laundry dryer will not close for more than a month. 2. Dish washing temperature not at the proper temperature and not enough to sanitize all the utensils. 3. Water dripping from the freezer for a long period of time. 4. Staff eating inside the kitchen. 5. Staff brought blankets inside the kitchen. 6. Pneumonia vaccination not offered to some of the residents. 7. Residents right to go back to his previous bed and replacement of resident belongings. 8. The nursing staff failed to ensure call light are within reach. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure their kitchen freezer and dryer were maintained in an operational condition for 86 of 86 residents by failing to: 1. Ensure the kitchen freezer would not have an ice buildup on the door of the freezer and was leaking water to the walk-in refrigerator. 2. Ensure dryer # 1's door in the laundry room was able to close to maintain the proper temperature and temperature of dryers are being monitored. These failures had the potential to affect residents 'health and put residents at risk for spread of infection and food-borne illnesses (any illness resulting from ingestion of food contaminated with bacteria, viruses, or parasites).

Inspectors wroteBased on observation, interview, and record review the facility failed to provide dignity and respect for three ( Resident 2, Resident 24, and Resident 62) of 20 sampled residents by failing to: a. replace resident boombox (a portable sound system, typically radio, CD player capable of powerful sound) for one sampled resident (Resident 2). b. Provide a dignity or privacy bag (urinary drainage bag holder that restores the dignity of a catheterized [insertion of a tube into the bladder to allow urine to drain for collection] on Resident 62's and Resident 24 indwelling catheter (a hollow tube that drains urine from the bladder into a bag outside the body). These failures had the potential to result into Resident 2's, Resident 24's and Resident 62's low self-esteem and privacy being violated. [...]

Inspectors wroteBased on observation, interview, and record review, the nursing staff failed to ensure call lights were within reach for four of four sampled residents (Residents 4, 14, 65 and 294). This deficient practice had the potential to delay any assistance the Resident's might need, and have a negatively affect their quality of left due to unmet needs.

Inspectors wroteBased on interview and record review, the facility failed to report a verbal abuse allegation to the State Licensing Agency ([CDPH] California Department of Public Health), the Ombudsman, and law enforcement agency for one of two sampled residents (Resident 299), when Resident 299 expressed feeling uncomfortable to be in the same room with Resident 51. This deficient practice resulted in the CDPH not being alerted to an allegation of abuse and also had the potential for a delay in the investigation of the allegation of abuse and for Resident 299 to experience continued abuse.

Inspectors wroteBased on interview and record review, the facility failed to investigate a verbal abuse allegation to the State Licensing Agency ([CDPH] California Department of Public Health), the Ombudsman, and law enforcement agency for one of two sampled residents (Resident 299), when Resident 299 expressed feeling uncomfortable to be in the same room with Resident 51. This deficient practice resulted in the CDPH not being alerted to an allegation of abuse and also had the potential for a delay in the investigation of the allegation of abuse and for Resident 299 to experience continued abuse.

Inspectors wroteBased on observations, interview and record review the facility failed to provide appropriate and consistent activities for three of seven sampled residents (Resident 4, 14 and 65). This deficient practice had the potential to decrease physical, cognitive, emotional health, and sense of belonging.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure two sampled residents (Resident 2 and 4) receive the necessary activities and exercises services needed. This deficient practice had the potential to result in Resident 2 and Resident 4 not receiving the quality of care that was needed.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the planned menu for polenta on two ( Resident 57 and Resident 73) of 20 sampled residents who are on fortified diet ( foods that have nutrients added to them to make them more nutritionally complete). This failure had the potential for Resident 57 and Resident 73 to receive the wrong caloric intake and not meet their nutritional needs which could lead to weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to: a. ensures the licensed nurse labeled and dated gastrostomy tube feeding formula and syringes for Resident 294. b. ensure to remove the midline (a long, thin, flexible tube that is inserted into a large vein in the upper arm) catheter using aseptic technique( a method used to prevent contamination with microorganisms) for Resident 297. c. ensure staff personal belongings were not placed on Enhanced Barrier Precautions (EBP-infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes) bed after the bed was cleaned. d. ensure staff member would not store cooked pasta and tumbler in the clean laundry area. e. maintains an appropriate and recommended temperature of the dryer. [...]

Inspectors wroteBased on interview and record review the facility failed to offer the pneumococcal vaccine (vaccine that helps prevent pneumonia, an infection that inflames the air sacs in one or both lungs) to two of twenty sampled residents (Resident 7 and Resident 2). This failure had the potential to result in Resident 7 and 2 acquiring and transmitting pneumonia to other residents, staff, and visitors.

Inspectors wroteBased on interview and record review, the facility failed to ensure two out of four Certified Nursing Assistants (CNA's), CNA 4 and CNA 8 were provided the required dementia (a decline in memory, language, problem-solving and other thinking skills that affect a person's ability to perform everyday activities) care training necessary to ensure the continuing competence of the facility's nursing staff's knowledge and skills. This deficient practice could result in a delay and interruption of the provision of necessary care and interventions necessary when providing care to dementia residents.

Inspectors wroteBased on interview and record review the facility failed to ensure one of 20 sampled residents (Resident 48) documentation of a significant change of condition was documented and Medical Doctor (MD) was informed when Resident 48's oxygen saturation dropped to 78 percent (%). This failure resulted in resident 48 not receiving the appropriate care and necessary treatment for low oxygen levels.

Inspectors wroteBased on interview and record review the facility failed to ensure one of 20 sampled residents (Resident 57) received Restorative Nurse Aide (RNA, certified nursing aide program that helps residents to maintain their function and joint mobility) services and treatment to prevent further decrease in range of motion (ROM, full movement potential of a joint [where two bones meet]) and contractures (muscle and joint stiffness associated with joint deformities and pain). This failure resulted in Resident 57 not receiving the needed RNA services placing Resident 57 at risk for further decline in range of motion, and at risk for contractures.

Inspectors wroteBased on interview and record review, the facility failed to do an ongoing assessment and provide revised interventions for one of two sampled residents (Resident 62) who had weight loss. This failure placed Resident 62 for unplanned significant weight loss of 14 pounds([Lbs.] unit of measurement) in one month and at risk for continued weight loss.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide an effective pain management on one of five sampled residents ( Resident 197) by failing to: 1. Ensure Resident 197's pain level was assessed and reassessed in a timely manner. 2. Ensure appropriate pain medication was provided according to pain assessment. These failures placed Resident 197 at risk for unrelieved pain and delay of necessary treatment and care.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to provide services including procedures that ensure the accurate administering of all drugs and biologicals to meet the needs of one of 20 sampled residents (Resident #35) by failing to ensure medications were not left at her bedside. This deficient practice had the potential for Resident 35 to have a medication-related adverse consequence. During a review of Resident 35's admission Record (AR), the admission Record indicated Resident 35 was admitted to the facility on [DATE], with diagnoses including type 2 diabetes mellitus (chronic condition that affects how the body processes sugar), depression (a constant feeling of sadness and loss of interest, which stops you doing your normal activities), and morbid obesity (more than 80 to 100 pounds above ideal body weight). [...]

Inspectors wroteBased on interview and record review, the facility failed to develop care plans for two of three sampled residents (Residents 1 and 7), who smoked cigarettes and/or were observed smoking in the facility. This deficient practice resulted in the care needs related to Resident 1 and Resident 7 ' s smoking not being documented and had the potential of not being recognized or addressed which could lead to harm.

Inspectors wroteBased on observation, interview and record review the facility failed to prevent accidents by: a. Failing to provide supervision for three of three residents who smoked (Resident 1, Resident 2, and Resident 7) and failing to ensure: 1. Residents 1 and 2 were supervised while smoking in the patio. 2. Resident 2 did not have possession of his pack of cigarettes and a lighter. 3. Residents 1 and 7 were assessed for smoking safety before being allowed to smoke in the facility. 4. The interdisciplinary team ([IDT] a group of healthcare providers from different fields who work together or toward the same goal to provide the best care or best outcome for residents) developed individualized residents ' care plan for smoking for Residents 1 and 7. These deficient practices placed Residents 1, 2 and 7 at risk for injuries related to unsupervised smoking. b. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide safe and sanitary storage for Residents personal food for two of two residents ' (Resident 9 and 10) by failing to ensure: 1. Resident 9 and 10 ' s personal food was not stored in the refrigerator for employee personal food items. 2. Resident 9 and 10 ' s food items were labeled with the date when the food item was brought to the facility. 3. Resident 9 and 10 ' s personal food was stored in a refrigerator where the temperature of the refrigerator was monitored and maintained at the recommended temperature range. These deficient practices had the potential to result in contamination of residents' food items which can cause food-borne illnesses (food poisoning). Food borne illness if contracted by the facility's' vulnerable population can lead to other serious medical complications.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement infection prevention and control (practical, evidence-based approach preventing patients and health workers from being harmed by avoidable infections) measures as evidenced by the failure to: a. Ensure the hallways were clear of any dirty equipment for seventy-seven out eighty-seven residents. b. Ensure a deep clean (a very complete cleaning process that includes all parts of something, not just surfaces or places where dirt can be seen) was completed for 21 of 21 resident rooms after residents vacated the rooms. These failures had the potential to result in the continued spread of infections including Coronavirus disease (COVID-19 a potentially severe respiratory illness caused by a corona virus and characterized by fever, coughing, and shortness of breath) in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure Certified Nursing Assistants (CNAs 3, 6, 7 and 8) who were contracted through a nurse Registry (a business that connects clients with licensed/registered nurses) to work at the facility, received abuse training and/or was made aware of who the abuse coordinator in the facility was before being assigned resident care. This deficient practice resulted in the inability of the facility to ensure that CNAs 3, 6, 7, and 8 knew the abuse regulations as mandated by the California Department of Public Health (CDPH) and per their facility ' s policy and procedure (P/P). This deficient practice had the potential to place residents at risk for abuse.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement Coronavirus disease (COVID-19 a potentially severe respiratory illness caused by a corona virus and characterized by fever, coughing, and shortness of breath) outbreak response measures (acts and procedures to minimize the spread of a disease) as evidenced by the facility failure to: a. Ensure Licensed Vocational Nurse (LVN) 3 was wearing an N95 mask (well fitted mask that filters airborne particles) and not eating potato chips while typing on the keyboard at the nursing station. b. Ensure Certified Nurse Assistant (CNA) 2 was wearing a mask while feeding one of one random resident. c. Ensure two visitors was screened for signs and symptoms of covid-19, by Registered nurse (RN) 1, prior to entry to the facility. d. [...]

Inspectors wroteBased on interview and record review, the facility failed to assess resident eligibility and offer pneumonia (an infection of the lungs) vaccination (medication to prevent a particular disease) for 2 of 5 sample residents (Resident 5 and 6) and offer influenza (contagious respiratory disease that can cause mild to severe illness) vaccination for Resident 6. These failures placed two residents at a higher risk of acquiring and transmitting the pneumonia and influenza to other vulnerable and immunocompromised (a weak immune system) residents in the facility.

Inspectors wroteBased on interview and record review the facility failed to offer the coronavirus 19 (Covid-19 a potentially severe respiratory illness caused by a corona virus and characterized by fever, coughing, and shortness of breath) vaccine (medication to prevent a particular disease) for two of two sampled residents (Resident 5 and 6). This failure placed Resident 5 and 6 at higher risk for acquiring Covid-19 infection.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure one of one Coronavirus disease ([Covid-19] a very contagious infectious disease) positive resident (Resident 4) had physician orders for Novel Respiratory Precautions (precautions to follow before entering a room of someone who has a newly identified germ that can cause respiratory infections). This deficient practice had the potential for the continued spread of Covid-19 to other residents and staff in the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure the: a. Minimum Data Set Nurse (MDSN) documented the date a care plan was started for one of one resident (Resident 3) and not when it should have started. b. Iinfection Preventionist Nurse (IPN) entered the order for isolation on the day she informed Medical Doctor (MD). These deficient practices had the potential to result in an inaccurate depiction of care rendered and received by the residents.

Inspectors wroteBased on interview and record review, the facility failed to implement their protocol for Antibiotic Stewardship (refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use) for one of three sampled residents (Resident 1). Resident 1 was prescribed antibiotic drug without meeting the criteria, after being screen for C-difficile (also known as Clostridioides difficile a germ that causes diarrhea and colitis (an inflammation of the colon) and urinary tract infection (UTI- infection in any part of the urinary system, the kidneys, bladder, or urethra). This failure had the potential for resident to develop antibiotic resistance (not effective to treat infection) from unnecessary or inappropriate antibiotic (medication to treat infection) use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control measures for an outbreak of Group A Streptococcal Infection (GAS: an infection that can spread through having contact with saliva, sharing utensils, or touching a wound of an infected individual) for four out of six sampled residents (Resident 1, Resident 4, Resident 5, Resident 6) by failing to: 1. identify why Resident 1, Resident 5, and Resident 6 is on Enhanced Barrier Precautions (EBP: infection control interventions to reduce transmission of multidrug-resistant organisms (MDROs: bacteria that is resistant to one or more antibiotics that help fight infections). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of one sampled resident's (Resident 1) electronic medical record (EMR- resident information including medical history, medications, diagnosis) was not left unattended when Licensed Vocational Nurse (LVN) 1 failed to exit out of the EMR after completing her medication administration. This deficient practice violated Resident 1's right to privacy and confidentiality.