Sunray Healthcare Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its Abuse Prevention Program, Abuse and Neglect, and Abuse Investigation and Reporting policies and procedures (P&P) for one of three sampled residents (Resident 1) reviewed for resident abuse by failing to: - Ensure Housekeeper 1 did not physically force Resident 1's right hand to open, causing Resident 1 to scream in pain on 5/9/2026 at 4 PM. -Ensure Registered Nurse 1 (RN1) identified and reported Resident 1's Family 1's allegation of physical abuse to the facility's Administrator (ADM), the Director of Nursing (DON), the Ombudsman (an official appointed to investigate individuals' complaints against maladministration), local police, and to the California Department of Health (CDPH) on 5/9/2026 at 4 PM. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure safe food storage practices in the kitchen when: 1. One bottle of thickened coffee was stored in the reach in fridge with an open date of 2/27/2026, exceeding storage period indicated in the manufacturer's instructions. 2. Bulk food (sugar) was stored inside trash bags that were not food grade (specialized bags designed for the safe storage, transportation, and packaging of food items intended for human consumption). These failures had the potential to result in harmful bacteria growth and cross contamination of food (transfer of harmful bacteria and chemicals from one place to another) that could lead to food borne illness in 67 of 75 residents (unidentified) who received food from the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the privacy and dignity of one of two sampled residents (Resident 90) reviewed for urinary catheter (a soft hollow tube which is passed into the bladder to drain urine, for persons who cannot empty their bladder in the usual way) by failing to ensure to cover the urinary catheter drainage bag as indicated in the facility's policy and procedure (P&P) titled Dignity. This failure had the potential to affect Resident 90's sense of self-worth and self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the personal belongings for one of one sampled residents (Resident 90) reviewed for personal property by failing to create an inventory list of Resident 90's belongings upon admission and readmission as per the facility's policy and procedure (P&P) titled, Personal Property dated 8/2025. This failure resulted in Resident 90's missing personal belongings.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure to accurately code the Minimum Data Set (MDS, a resident assessment tool) for one of two sampled residents (Resident 8) reviewed for antibiotics (medication that help stop infection caused by bacteria) by failing to: -Ensure to code Resident 6's use of antibiotics and diagnosis of cellulitis (serious bacterial infection of the deeper skin layers, causing painful, red, swollen, and hot legs or feet) of the left and right lower limbs (legs) on the MDS dated [DATE]. This failure had potential to negatively affect the provision of necessary care and services for Residents 8.

Inspectors wroteBased on interview and record review the facility failed to develop a care plan for range of motion (ROM, the full movement potential of a joint) for one of six sampled residents (Resident 2) reviewed for limited ROM. This failure placed Resident 2 at risk for functional decline and had the potential to affect Resident 2's care and services received.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to ensure one of two sampled residents (Resident 6) reviewed for activities of daily living (ADL's- activities related to personal care, including bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating) and was dependent on staff (helper does all of the effort) received care in accordance with the residents' plan of care by failing to:-Ensure the nursing staff (in general) assisted Resident 6 with meals on 4/19/2026 at 8:12 AM. This failure had the potential for Resident 6's increased the risk of inadequate nutrition and aspiration due to dysphagia (difficulty swallowing).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 90) reviewed for urinary indwelling catheter (a flexible tube that is inserted through the urethra [passageway between the bladder and the external part of the body, which allows urine to be excreted from the body] and into the bladder and left in place to drain urine) received the necessary urinary catheter care by failing to: -Ensure Resident 90's urinary catheter drainage bag did not touch the floor. This failure placed Resident 90 at risk for urinary tract infection (infection caused by bacteria).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication administration or accurate accountability of all controlled medications (medications with a high potential for abuse) for one of four sampled residents (Resident 6) by failing to:-Document the removal of Lacosamide (a medication used for seizure disorder, a condition characterized by abnormal electrical activity in the brain that leads to sudden changes in behavior, movement, feelings, or consciousness) for administration to Resident 6 on the Controlled Drug Record (CDR, a detailed record that tracks the receipt, administration, disposal, and inventory of controlled substances [use are regulated by law due to its potential for abuse, dependence, or harm]). [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure that a licensed pharmacist performed a monthly medication regimen review (MRR, when a consultant pharmacist reviews and analyzes a resident's medication list, ensuring that the medications are appropriate, effective, and safe) to identify potential clinically significant medication issues, including unnecessary drugs, for one of 18 sampled residents (Resident 4). This failure had the potential to result in unmonitored adverse drug reactions (undesired and harmful effects that occur because of medication, treatment, or procedure) and inappropriate medication usage for Resident 4.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of 36 resident rooms (room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]) met the 80 square feet (sq. ft.) per resident. room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER] consisted of three-bedroom capacity. This failure had the potential to result in inadequate space to provide safe nursing care and privacy for the residents (unidentified) who resided in room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER].

Inspectors wroteBased on interview and record review, the facility failed to implement the facility's policy and procedure (P&P) titled, Abuse, Neglect [s the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress], Exploitation (taking advantage of a resident for personal gain through the use of manipulation, intimidation, or threats) and Misappropriation Prevention Program, for one of three sampled residents (Resident 1) reviewed for abuse by failing to: -Ensure to provide one-on-one abuse training for Certified Nurse Assistant 3 (CNA3) prior to having direct-care responsibilities for residents following a three-day suspension after an allegation of abuse. This failure had the potential to place Resident 1 at risk for abuse, neglect, and feeling intimidated.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1), reviewed for behavioral health services who had a diagnosis of depression (a mood disorder that causes persistent feeling of sadness and loss of interest) received appropriate mental health services and support. On 1/1/26, R1 alleged that CNA3 abused her, and on 1/5/26, R1's physician noted that R1 had increased nighttime anxiety and was afraid to fall asleep. The facility failed to identify R1's increased anxiety and failed to implement care-planned interventions in response to R1's change in behavioral health symptoms.

Inspectors wroteBased on interview and record review the facility failed to ensure Licensed Vocational Nurse1 (LVN1), Certified Nursing Assistant 1 (CNA1), and Restorative Assistant 1 (RNA1) performed cardiopulmonary resuscitation (CPR, a life-saving procedure used when someone's heart or breathing has stopped) with no delays to one of four sampled residents (Resident 1), who was found with no mobility (movement), no reaction, not responding, and lifeless, on 12/31/2025 at approximately 1:10 PM to 1:15PM by failing to: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) reviewed for pureed diet (a pudding-like texture that is smooth, blended) diet received food consistent with the ordered diet by failing to: [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a specific and individualized person-centered care plan (a plan of care that summarizes a resident's health conditions, specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of a condition, and current treatments) for dysphagia (difficulty swallowing) for four of four sampled Residents (Resident 1, Resident 2, Resident 3, and Resident 4) reviewed for care plans. This failure placed Resident 1, Resident 2, Resident 3, and Resident 4 at an increased risk for aspiration (when something enters the airway or lungs by accident) and choking. Cross Reference F678 and F689.

Inspectors wroteBased on observation, interview, record review, and the facility policies and procedures (P&P) titled Controlled Medication Storage, last reviewed 8/28/2025, Controlled Medication Disposal, last reviewed 8/28/2025, the facility failed to:1. Reconcile (the process of comparing transactions and activity to supporting documentation) four (4) medication emergency kits (eKITs - kits containing medications needed to be used during emergencies) containing Controlled Substances (CM, Controlled Medications - medications which have a potential for abuse and may also lead to physical or psychological dependence) for September 2025, in one of one inspected medication storage rooms (Medication room [ROOM NUMBER].) 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure three of seven sampled residents (Resident 6, Resident 44, and Resident 47) were free from significant medication errors (mistakes when giving medications that can cause the resident discomfort or jeopardizes his or her health and safety) according to professional standards of practice. By failing to ensure facility staff rotated the administration site (the practice of moving the injection spot to different places on the body, like the stomach, arms, thighs, or buttocks, to allow previous spots to heal) when administering insulin (a hormone that acts like a key to let sugar (glucose) from the blood enter the body's cells for energy) as per physician's orders and the facility's policy and procedures (P&P) titled Insulin Administration dated 8/25/2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store the insulin and albuterol when they stored it in the non-hazardous waste bin. On 9/30/2025 at 11:08 a.m. three used insulin (is a natural hormone [is chemicals that coordinate different functions in the body] that turns food into energy and manages the blood sugar level made with metacresol [m-cresol - a toxic and corrosive preservative]) pens, and; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when:a. A pack of hot dogs and three cartons of protein shake were found in the resident refrigerator with no receive dates. b. Dietary Aid 1 (DA1) was observed wearing multiple pieces of jewelry (necklace, rings and bracelets) and watches. These deficient practices have the potential to promote foodborne illness and cross- contamination due to improper food handling, storage and hygiene practices.

Inspectors wroteBased on interview and record review the facility failed to develop a resident centered comprehensive care plan (a document outlining a detailed approach to care customized to an individual resident's need) for one of two residents (Resident 7). By failing to create and implement a care plan once a physician's order was received on 7/2/2025 for a right-hand mitten (padded mitted, used prevent the individual from using their hands to inadvertently or intentionally disrupt medical treatment or cause self-harm). As a result, Resident 7 did not have a care plan in place for the right-hand mitten from 7/2/2025 until 9/29/2025. Placing the resident at risk of receiving inadequate care and monitoring, which could affect Resident 7's quality of care and could cause the resident harm. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide necessary respiratory care services for one out of eight sampled residents (Resident 12) by failing to label Resident 12's oxygen cannula tubing (small, flexible tube with two prongs that fit into the nostrils to deliver extra oxygen to someone who has trouble breathing) with the date changed according to of the facility's policy and procedure (P&P), titled Departmental (Respiratory Therapy) - Prevention of Infection, dated 8/28/2025 This deficient practice had the potential for Resident 12 to experience respiratory infections. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of one resident's (Resident 62) food preferences were honored as documented in Resident 62's Dietary Profile/Preferences, dated 11/12/2025. This Deficient practice had the potential to result in decreased meal satisfaction, decrease caloric intake, dehydration (a condition where your body loses more fluids than it takes in, meaning it doesn't have enough water to perform its normal functions), and malnutrition (when your body doesn't get enough of the right nutrients to stay healthy). [...]

Inspectors wroteBased on interview and record review, the facility failed to perform required staff competency evaluations (an evaluation of the skills, knowledge, and abilities of a staff member) for two of three sampled staff (Certified Nursing Assistant 1 [CNA1] and CNA3) in accordance with the facility's Performance Evaluations policy and procedure. This deficient practice had the potential for residents not to receive the appropriate care and services needed, which could affect the quality of care received, and potentially lead to resident harm. During a concurrent interview and record review on 7/28/2025 at 12:11 PM with the Director of Staff Development (DSD), CNA1 and CNA3 files were reviewed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a clean, odor free, homelike environment for one of four sampled residents (Resident 1), by failing to maintain an urine odor free environment and maintain the gray fall mat at the right side of Resident 1's bed clean, dry and odor free. This deficient practice resulted in a strong odor of urine lingering around the resident's bed and room entrance, and a dirty, wet, smelly fall mat, leading to an unkempt, un-homelike environment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to infuse the proper amount enteral feeding (a method of providing nutrition directly into the gastrointestinal (GI) tract, typically through a feeding tube) of diabetic source 1.2 calories per milliliter (ml) at 80 ml an hour for 20 hours with a total volume of 1600 ml or 1920 calories, continue until dose is met as ordered by the physician for one of four sampled residents (Resident 1). This failure resulted in the resident not receiving the ordered nutrition had the potential to cause a low caloric intake that could result in malnutrition, dehydration, unexpected weight loss, and decline in overall health. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication administration and accurate accountability of controlled medications (high potential for abuse) as indicated in the facility's policy and procedures (P&P) for four of four sampled residents (Resident 6, Resident 18, Resident 73, and Resident 80) observed during the medication administration by failing to: -Ensure Resident 80's blood pressure (BP) medication, Amlodipine 5 milligram ([mg] - a unit of measure for weight) was administered as ordered and the physician was notified when administered over an hour later than the 9 AM scheduled administration six times, between 4/7 to 4/21/2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff followed the Reduced Concentrated Sweets (RCS) diet for blood sugar control, according to the facility's food portioning and serving guide spreadsheet instructions. By failing to ensure residents on RCS diets did not receive garlic bread for lunch on 4/21/2025. This deficient practice could result in increased blood sugar levels for 13 of 64 residents who were on RCS diet.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen, by failing to ensure resident cups, trays, and dishes were clean prior to removing from the dish machine and storing to air dry. This deficient practice had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness in 64 out 69 residents who received food from the facility kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodations for resident needs by not having the call light within reach for two of 22 sampled residents (Resident 13 and Resident 61) observed for call light placement. The deficient practice had the potential for residents not being able to call facility staff for help as needed.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled resident (Resident 399) reviewed for Beneficiary Notification was provided with a Notice of Medicare Non-Coverage (NOMNC - a notice that is provided to beneficiaries that indicates when their Medicare covered services are ending). This deficient practice had the potential to result in the resident not being informed of their coverage end date and not being able to exercise their right to file an appeal.

Inspectors wroteBased on interview and record review, the facility failed to ensure three out of ten facilitiy staff (Registered Nurse [RN 1], Licensed Vocational Nurse [LVN 6], Certified Nurse Assistant (CNA 4) reviewed for personal file had a background check prior to employment. This deficient practice caused an increased risk to the safety of the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 71) with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice. Resident 71 was not repositioned(turn from side to side) in her bed every two hours per the care plan. This deficient practice had the potential for Resident 71 to experience worsening of pressure ulcers (bedsores - areas of damaged skin and tissue caused by sustained pressure that reduces blood flow to vulnerable areas of the body) / injuries to the resident.

Inspectors wroteb. A review of Resident 63's admission Record indicated the resident was readmitted to the facility on [DATE] with diagnoses including dependence on respiratory ventilator, chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing), chronic respiratory failure with hypoxia or hypercapnia ,and amyotrophic lateral sclerosis (ALS - also known as Lou Gehrigsdisease is a disease that affects nerve cells in the brain and spine). A review of Resident 63's H&P dated 11/24/2024, indicated Resident 63 was on a ventilator with tracheostomy and had mental capacity (a person's ability to understand information and make decisions for themselves). [...]

Inspectors wroteBased on interview and record review, the facility failed to clarify the physician's orders for hydrocortisone cream (a topical steroid cream applied to the skin to reduce inflammation, redness, itching and swelling) as recommended by the facility's consultant pharmacist (a healthcare professional, who provides specialized expertise to healthcare facilities, typically focusing on ensuring the safe and effective use of medications) during the Monthly Medication Regimen Review (MRR, when a consultant pharmacist reviews and analyzes a resident's medication list, ensuring that the medications are appropriate, effective, and safe) dated 1/13/2025, for one of three sampled residents (Resident 49) reviewed for Unnecessary Medications and Medication Regimen Review. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility's medication error rate (observed or identified preparation or administration of medications or biologicals which was not in accordance with the physician's order, manufacturer's specifications for the preparation and administration of the medication or biological, and professional standards of practice) was not five percent (5%) or greater. There were seven medication errors out of 28 opportunities (observations during medication administration) for error, to yield a cumulative error rate of 25 % for one of four sampled residents (Resident 80) observed during the medication administration. [...]

Inspectors wroteBased on interview and record review the facility failed to develop a person-centered care plan for one of three sampled residents (Resident 1). Resident 1 did not have a care plan for his diagnosis of depression. This deficient practice caused an increased risk in Resident 1 experiencing sadness and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to implement the resident's care plan intervention of weekly skin assessments for one of 15 sampled residents (Resident 1). This failure had a potential to negatively affect the delivery of care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program by failing to ensure one of two mobile linen carts positioned outside of the activity room was covered while unattended. This deficient practice caused an increased risk to the facility maintaining a safe and sanitary environment to prevent the spread of infections among residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) care plan was developed for left trochanter (hip) pressure injury stage four (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone). This failure had the potential to pose the risk of not providing appropriate, consistent, and individualized care to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to implement the policy and procedure (P&P) titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, to ensure a background check for staff was conducted prior to the start of employment for two of three sampled staff (Licensed Vocational Nurse [LVN 1] and Certified Nurse Assistant [CNA 2]). This deficient practice caused an increased risk in the protections for health and rights of the residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident 2) had current documented diagnoses to support the administration of psychotropic medications (drugs that affect the brain and mind, altering a person's thoughts, emotions, feelings, awareness, and perceptions). This deficient practice could result in a delay of treatment without a diagnosis attached to the psychotropic medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1), who was administered oxygen, received care in accordance with professional standards of practice and the comprehensive person-centered care plan. Resident 1 was found smoking in his room and the smoking care plan was not updated or revised. This deficient practice caused an increased risk in a negative outcome to Resident 1's physical and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection control program to ensure prevention and development of communicable diseases for five sampled staff members (Certified Nursing Assistant 1, 2, 3, and Licensed Vocational Nurse 1 and 2). Facility staff were not in compliance with the mandatory respirator (a mask or device worn over the mouth and nose to protect the respiratory system by filtering out dangerous substance) fit testing requirement. This deficient practice had the potential to expose residents, employees, and the community to health hazards and airborne transmissible infectious diseases (bacteria or viruses most commonly transmitted through small respiratory droplets).

Inspectors wroteBased on interview and record review, the facility failed to offer influenza (flu, an infection of the nose, throat, and lungs), pneumonia (an infection that inflames the air sacs in one or both lungs), and Coronavirus (COVID-19, a contagious viral illness that causes mild to severe respiratory illness with symptoms such as fever, cough, shortness of breath, sore throat, and congestion) vaccines (a biological preparation that provides active acquired immunity to a particular infectious or malignant disease) to one of five sampled residents (Resident 1). This deficient practice placed Resident 1 at increased risk of acquiring the flu, pneumonia, and COVID-19; and had the potential for Resident 1 to transmit these viruses to other residents and staff at the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) felt safe when another resident (Resident 2) wandered into their room in the middle of the night and kissed them on the cheek. This failure resulted in Resident 1 feeling nervous and violated.

Inspectors wroteBased on interview and record review, the facility failed to implement the individualized interventions to address the resident ' s dementia (a disorder of mental processes caused by brain disease or injury and marked by memory disorder, personality changes, and impaired reasoning) care needs for one of two sampled residents (Resident 2). This deficient practice resulted in Resident 2 wandering into another resident ' s room (Resident 1) and kissing Resident 1 on the cheek.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain clean and sanitary fall mats (provide a cushioned surface to absorb the impact of a fall), while in use inside two out of four sampled resident ' s room (Resident1 and Resident 2). This failure has a potential to expose residents to germs and spread an infection in the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure their acting Infection Preventionist ' s (IP, a professional with special training in maintaining and implementing the infection control program at a healthcare facility) certificate or training records for infection prevention and control were available and accessible. This deficient practice had a potential for the facility ' s infection prevention and control program not being maintained, placing the residents and staff at risk for healthcare-associated infections (HAIs- are infections you can get while in a healthcare facility).

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility ' s employee handbook was followed for three of three sampled Certified Nursing Assistants (CNA 1, CNA 2, and CNA 3) by failing to conduct a performance evaluation every 12 months. This failure resulted in no yearly performance evaluations done for CNAs 1, 2, and 3 and had the potential to effect resident care.

Inspectors wroteBased on interview, and record review, facility failed to ensure the resident's right to be treated with dignity and respect was promoted for two of five sampled residents (Residents 1 and 5). This failure resulted in Residents 1 and 5 not being treated with dignity and respect and had the potential to affect the resident ' s self-esteem and self-worth. Cross reference with F677.

Inspectors wroteBased on interview, and record review, the facility failed to ensure incontinence care was provided a timely manner for one of five sampled residents (Resident 1). This deficeint practice had the potential to result in infection, illness and effect the resident ' s self-esteem and quality of life. Cross Reference:F550.

Inspectors wroteBased on interview and record review, the facility failed ensure discharge orders were followed for one of four sampled residents (Resident 1). This deficient practice resulted in Resident 1 being discharged home without the ordered oxygen concentrator (device that separates nitrogen from the air around you so you can breathe up to 95% pure oxygen).

Inspectors wroteBased on interview and record review, the facility failed ensure, admission orders from the General Acute Care Hospital (GACH) were accurately transcribed and reconciled, and orders per admission protocol for monitoring of vital signs (measurements of the body's most basic functions including; oxygen saturation [O2 sat, saturation by percentage of oxygen in the blood], heart rate, respiratory rate, blood pressure, and temperature) were entered for one of four sampled residents (Resident 1). This deficient practice resulted in no orders entered for oxygen therapy and vital sign monitoring upon admission and therefore were not done for Resident 1.

Inspectors wroteBased on observation, interview, and record review the facility failed to post the total number and the actual hours worked by the licensed and unlicensed nursing staff directly responsible for resident care per shift with actual date. This deficient practice had a potential to cause the misinformation to the public and residents regarding the most current staffing levels which could violate the residents' rights to know staff who took of them.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its abuse policy and procedure by failing to investigate staff-to-resident alleged abuse for one of five sampled residents (Resident 4). This deficient practice had the potential to result in unidentified abuse in the facility and failure to protect residents from abuse.

Inspectors wroteBased on observation, interview the facility failed to maintain a clean, odor-free, well-kept environment for one of five sampled residents (Resident 4), by failing to ensure the resident ' s room and adjacent hallway were odor free and Resident 4 ' s floor around the bed area was not sticky. This deficient practice resulted in foul-smelling environment and sticky floor in and around Resident 4 ' s room.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain fingernails of one of five sampled residents (Resident 4), trimmed and free of dirt and debris ( the remains of something broken down or destroyed). This deficient practice had the potential to result to odors, infection, unkempt fingernails, poor hygiene, and embarrassment. in infection, illness and effect the resident ' s self-esteem and quality of life. A review of Resident 4 ' s admission record, dated 5/22/24, indicated, Resident 4 was admitted to the facility on [DATE] with diagnoses including muscle weakness, need for assistance with personal care, hypertension (high blood pressure) and hyperlipidemia (high levels of fat particles [lipids] in the blood). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff turned and repositioned one of four sampled residents (Resident 1), every 2 hours (Q 2hrs) and as needed (PRN) to prevent pressure sores (also known as pressure ulcer, pressure injury, or bed sore - is an injury to the skin that develops over bony areas of the body from prolonged pressure to the area) according to physician's order and facility's policy and procedures. Resident 1 was identified as at high risk for regression of pressure sores/injuries and was at high risk to develop new pressure sores. [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150 B of the Act. The facility failed to report to the state survey agency within two hours an allegation of physical abuse directed toward one of three sampled residents (Resident 1) by Certified Nursing Assistant 1 (CNA 1) on 3/16/2024. This deficient practice resulted in a delay of an onsite inspection by the California Department of Public Health to ensure Resident 1's circumstance were investigated. This deficient practice also had the potential to place Resident 1 at further risk for abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of abuse was thoroughly investigated and immediately place effective measures in order to prevent further or potential abuse for one of three sampled residents (Resident 1). After Licensed Vocational Nurse 1 (LVN 1) reported an allegation of physical abuse to Registered Nurse 1 (RN 1) on 3/16/2024, Certified Nursing Assistant 1 (CNA 1) was not immediately removed from providing direct care and continued to have access to the resident. As a result of this deficiency, Resident 1 was not protected from the potential of further harm or retaliation from the staff after being identified.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident, who was at risk to leave the facility and had expressed to multiple staff that he wanted to leave, did not elope (Resident leaves the premises or a safe area without the facility's knowledge and supervision) from the facility for one of four sampled residents (Resident 1). The facility failed to: 1. Assess Resident 1's risk for elopement upon admission. 2. Implement their care plan interventions to check resident's whereabouts. 3. Communicate with the facility staff the planned intervention of every 30 minutes monitoring for Resident 1 who is at risk to leave the facility. 4. Identify Resident 1's risk for elopement behavior of repeatedly asking to leave the facility. 5. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Medication Administration Record (MAR) for intravenous (IV) medication Zosyn (used to treat many different infections caused by bacteria, such as stomach infections [occurs when germs enter the body, increase in number, and cause a reaction of the body], skin infections, pneumonia, and severe uterine infections) was complete and accurate for one of eight sampled residents (Resident 7). This deficeint practice resulted in an inaccurate and incomplete documentation.

Inspectors wroteBased on interview and record review the facility failed to ensure the policy and procedures for a change in condition (COC - a deterioration in health, mental, or psychosocial status in either life-threat- ening circumstances or clinical complications) was followed for one of four sample residents (Resident 1). This failure resulted in Resident 1 ' s COC not being assessed in a timely manner by staff.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of four sampled residents ' (Resident 2), medications were stored safely in medication cart and not at resident ' s bedside. This failure had the potential to result in Resident 2 taking extra doses of the medications.

Inspectors wroteBased on interview and record review the facility failed to implement measures to prevent fall and injury for one of three sampled residents (Resident 1). For Resident 1, who was confused, with unsteady gait and history of falls, the facility failed to: 1. Supervise and monitor the whereabouts of Resident 1. 2. Identify interventions related to the resident's specific risks and causes to try to prevent resident from falling and try to minimize complications from falling As a result, Resident 1 suffered five unwitnessed falls on 8/20/23, 9/5/23, 9/27/23, 11/19/23, and 11/23/23. On 11/23/23 at 2 p.m., Resident 1 was found with his face down in his room and was bleeding from the right side of the head and required transfer to general acute hospital 1 (GACH 1) by paramedics (Medical professionals who specializes in emergency treatment). [...]

Inspectors wroteBased on interview and record review, the facility failed to provide an environment that was free of accident hazards for one of three sampled residents (Resident 2), by failing to ensure call lights were answered timely. This deficient practice resulted in Resident 2 falling on 12/11/2023 sustaining a laceration to the back of the head requiring transfer to the GACH (General Acute Care Hospital).

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sample residents (Resident 1) was free from medication errors. By failing to: 1. Ensure Resident 1 received the ordered medication Isosorbide Mononitrate (medication used to lower blood pressure) ER (extended release) 60 mg (milligram) oral tablet one tablet by mouth in the morning (6:30 am) on 12/6/23, 12/7/23, and 12/9/23. 2. Follow Resident 1 ' s physician ' s orders for blood sugar (BS) interventions (when resident ' s blood sugar was at 401 millimoles per liter [mmol/L] or above) were followed on: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), had interventions in place for medical device-related pressure sore (pressure ulcer/ injury resulting from use of a medical device, equipment, furniture, or everyday objects in direct contact with skin and because of increased external mechanical load leading to soft tissue damage) prevention. This failure had the potential to result in Resident 1 developing a pressure sore on his posterior (rear) thigh, due to a medical device -- the resident ' s foley catheter (a flexible plastic tube inserted into the bladder to provide continuous urinary drainage via drainage tubing and urine collection bag) tubing.

Inspectors wroteBased on interview, and record review, the facility failed to identify and ensure one of three sampled residents (Resident 77), who had a diagnosis of Human Immunodeficiency Virus (HIV - a virus that attacks the body's immune system), received care, treatment, and services in accordance with professional standards of practice by failing to: - Conduct a comprehensive reassessment of Resident 77, including risk for immunocompromised (immune system's defenses are low, affecting its ability to fight off infections and diseases) status. - Conduct an Interdisciplinary Team (IDT - a group of health care professionals from different fields who coordinate resident care) meeting to address Resident 77's HIV positive status. -Develop and implement a care plan with specific interventions for Resident 77's HIV positive status. [...]

Inspectors wroteThis is a repeated deficiency from the Recertification Survey on 12/2/2023 with a s/s=F. Based on interview and record review the facility failed to provide adequate and sufficient nursing staff to meet the needs of one of three sampled residents (Resident 1). This repeated deficient practice caused an increased risk in the care of the total resident population (66 residents), effecting resident safety, security, and implementation of policies and procedures necessary to remain in compliance with current laws, regulations and guidelines. There was inadequate availability of nursing services on 1/9/2024 to assure resident safety and attainment of the highest practicable mental and psychosocial well-being of Resident 1. As a result, on 1/18/2024, Resident 1 stated he did not receive his 1 AM sleeping medications until 5:30 AM. Resident 1 stated, I don't feel safe. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two of four sampled staff (Licensed Vocational Nurse) 3 and Certified Nursing Assistant (CNA) 1 had valid Basic Life Support (BLS - a certification for healthcare professionals who need to know how to perform CPR, as well as other lifesaving skills, in a wide variety of in-hospital and out-of-hospital settings) certification. This deficient practice had the potential for residents to not receive appropriate emergency care during life-threatening situations.

Inspectors wroteBased on interview and record review, the facility failed to report an injury of unknown origin within 24 hours for one of nine sampled residents (Resident 1). This deficient practice resulted in Resident 1 ' s injury of unknown origin not being reported to state licensing/certification office and delayed the investigation to determine the cause of the injury and rule out abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure care plan was developed post incident for one of two sample residents (Resident 2). This deficient practice had the potential to negatively affect the delivery of care and services for Residents 2.

Inspectors wroteBased on interview and record review the facility failed to ensure call lights were answered and residents ' needs are attended to for two of 10 sampled residents (Resident 2 and Resident 3). The facility failed to answer the call lights timely when Resident 2 and Resident 3 called for assistance. These deficient practices resulted in Resident 2 and Resident 3 stating that they felt frustrated.

Inspectors wroteBased on interview and record review the facility failed to follow physician ' s order to hold (not to administer) hydralazine hydrochloride (HCL, medicine for high blood pressure) 25 milligrams (mg., unit of measurement) for systolic blood pressure (SBP, the top blood pressure number) less than 120 millimeters of mercury (mmHg). On 8/20/2023 at 5:45 p.m., Resident 1 ' s blood pressure (BP) was 116/64 mmHg and licensed vocational nurse 2 (LVN 2) administered hydralazine HCL 25 mg by mouth to Resident 1. The facility failed to hold the hydralazine HCL on 8/20/2023, at 9 a.m., 1 p.m. and 5 p.m. when Resident 1 ' s SBP was less than 120 mmHg. As a result, , Resident 1 became weak, had syncopal episode (passed out), and was unresponsive (a state in which a person becomes unaware and does not respond to touch, light, sound). [...]

Inspectors wroteBased on interview, and record review, facility failed to ensure dignity for one of 8 residents sampled (Resident 2) by failing to ensure Resident 2 was addressed by his name during care by Licensed Vocational Nurse (LVN) 1. This failure resulted in Resident 2 not being treated with dignity and respect and had the potential to affect the resident ' s self-esteem and self-worth.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a licensed administrator was onsite to manage the facility. This failure had the potential to affect resident care and management of the facility.