Tarzana Health and Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly when: 1. Two dumpsters (a movable waste container designed to be brought and taken away by special collection vehicles, or to a bin that specially designed garbage truck lifts) were overflowing with garbage and were not completely closed when not in use. 2. The area surrounding the dumpsters contained scattered debris on the ground including green beans, carrots, soiled gloves, empty food containers, and plastics. These failures had the potential to attract pests such as rats, cockroaches, flies, and ants, which may spread diseases to 165 of 165 residents living in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the confidential personal information of residents were protected by failing to ensure documents (menu tickets) containing protected information ([PHI]- any health information that can be used to identify specific individual which must remain confidential to prevent harmful consequences) were shredded prior to disposing in the waste container. This deficient practice had the potential to violate 157 of 167 residents' rights for privacy and confidentiality of personal and medical records.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. Licensed nurses practiced professional standards of practice by failing to carry out the physician's order to have the right arm sling (a supportive medical device designed to immobilize and protect the arm) on at all times during two observations for one of three sampled residents (Resident 2) investigated under position and mobility. This deficient practice resulted in the resident not receiving the necessary care and services in accordance with the professional standards of practice. 2. One of one sampled resident (Resident 12) received treatment and care in accordance with professional standards of practice when a licensed nurse did not assess, document, notify the doctor, obtain orders, and initiate a care plan for a new wound to the resident's left lower leg. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents receive proper assistive devices to maintain vision and hearing abilities for three of three sampled residents (Resident 43, Resident 79, and Resident 87) by failing to: 1. Ensure Resident 43 and Resident 79 wore hearing aids (a device worn in or behind the ear designed to amplify sound for individuals who have difficulty hearing) inserted in the ear canal (a small pathway that runs from the outer ear to the middle ear and helps a person hear) as ordered by the physician. This deficient practice had the potential to result in Resident 43 and Resident 79 inability to maintain hearing ability. 2. Ensure ophthalmology (branch of medicine dealing with the diagnosis, treatment, and surgery of eye disorders and visual diseases) consultation was arranged for Resident 87. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the menu and did not meet nutritional needs when: 1. Staff did not follow the recipe for green beans. 2. Staff did not follow the portion size of three (3) ounces (oz, unit of measurement) and served two (2) oz for pork roast recipe to regular and therapeutic diets (a specialized meal plan prescribed by a healthcare provider or registered dietician to treat a medical condition, manage symptoms, or aid in recovery). 3. Staff did not follow the portion size for large portion diet and served five (5) oz instead of 4.5 oz and for small portion diet served 1.5 oz instead of two (2) oz. [...]

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: 1. Reach in refrigerator gasket was torn. 2. Kitchen and storage areas were not free from dirt and debris. a. Reach-in refrigerator bottom shelves contained bread, cheese and other food debris. b. The walk-in refrigerator shelves had dust buildup. c. Reach-in freezer had dirt and food debris. d. Condiment container had salt, sugar, pepper and artificial sweeteners debris accumulation. e. The can opener has metal shaving residues f. Ice scoop storage had brownish particles. 3. Four (4) of 4 dented cans (a packaged metal food containers that have been physically deformed or crushed) were found with non-dented cans. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices for three of thirty-three sampled residents (Resident 1, Resident 10, and Resident 87) by failing to maintain complete and accurate documentation when: 1. Resident 1's 2025 influenza (a contagious respiratory illness caused by influenza viruses that infect the nose, throat, and lungs) vaccine (medications used to prevent diseases usually given by injection or by mouth) status was not in the medical record. 2. Resident 10 was incorrectly documented as English speaking instead of Spanish speaking. 3. Resident 87's active medical diagnosis for vision loss and retinal detachment of the left eye was nit documented on the resident's admission Record. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a document that outlines a resident's healthcare needs, goals, and the interventions planned to achieve those goals) for two of 33 sampled residents (Resident 3 and Resident 10) by failing to: 1. Address Resident 3's communication impairment. 2. Address Resident 10's primary language (Spanish). This deficient practice had the potential for Resident 3 and Resident 10 to be unable to make their needs known, understand staff, or receive adequate care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide proper care and treatment to maintain or improve a resident's communication abilities for one of one sampled residents (Resident 3) investigated under communication-sensory care area by failing to ensure Resident 3 had a communication board. This deficient practice had the potential to cause psychological distress for Resident 3 and delayed the provision of necessary care and treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure Registered Nurse 2 (RN 2) maintained a current cardio-pulmonary resuscitation (CPR - an emergency, life-saving technique performed when someone's breathing or heartbeat has stopped) certification from a CPR provider whose training includes a hands-on session in accordance with accepted national standards for one of six staff members investigated under competent nurse staffing task. This deficient practice allowed for staff without the appropriate CPR certification to work alongside 165 medically vulnerable residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment that is free from accident hazards for three of eight sampled residents (Resident 36, Resident 58, and Resident 168) investigated for accidents by failing to: 1. Ensure Resident 36 did not have a nightstand and bedside commode (portable toilet chair) on the floor mat (a mat placed on the floor next to a resident's bed or chair to minimize the impact of a fall). This deficient practice placed Resident 36 at increased risk for injury in the event of a fall. 2. Ensure a water pitcher and food were not at Resident 168's bedside who had a gastrostomy tube (g-tube -feeding tube surgically placed directly into the stomach) and a physician's order for nothing by mouth (NPO-not to eat or drink anything). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 49 and Resident 187) did not have a loop or kink (unwanted twist or bend) in their urinary catheter tubing (a hollow tube inserted into the bladder to drain or collect urine). This deficient practice had the potential for the residents to develop a urinary tract infection (UTI- an infection in the bladder/urinary tract).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate care and services to provide respiratory care for two of two sampled residents (Resident 14 and Resident 58) investigated under respiratory care area by: 1. Failing to ensure Resident 58 and 14's oxygen nasal cannula (NC - a device that delivers supplemental oxygen directly into the nostrils through two small prongs that rest inside the nostril) was correctly applied. 2. Failing to assess Resident 14's baseline oxygen saturation level before applying PRN (given as needed) oxygen and re-assess oxygen saturation level post-application of PRN oxygen. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a window screen did not have a gap in a shared resident room affecting two of five sampled residents (Residents 67 and 91) investigated under the Environment task. This deficient practice created an entry point and access for insects to get inside the building which can potentially transmit insect borne illnesses and negatively affect the residents' quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS - a resident assessment tool) assessment accurately reflected the vision and dental status and active diagnosis of vision loss and retinal detachment (the thin layer of tissue at the back of the eye [retina] pulls away from its usual position) of the left eye and diminishing vision of the right eye was reflected for one of thirty-three sampled residents (Resident 87). This deficient practice resulted in Resident 87 having an inaccurate MDS assessment and had the potential to negatively affect in the plan of care and treatment.

Inspectors wroteBased on interview and record review, the facility failed to report timely to the State Survey Agency (the Department) an acute fracture of the tip of the right olecranon process (a break in the bone of the tip of the elbow) with associated soft tissue swelling and a suspected fracture involving the greater tuberosity of the right humerus (a break in the bony prominence at the top of your upper arm bone) from an unknown cause for one of three sampled residents (Resident 1). This deficient practice resulted in a delay of investigation to rule out abuse. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a comprehensive person-centered care plan (a written course of action that helps a resident achieve outcomes that improve their quality of life) for one of three sampled residents (Resident 1) to address the use of a right arm sling (a supportive device, usually made of fabric, used to hold an injured arm, wrist, or shoulder in a resting position to relieve pain and prevent further injury) following an injury. This deficient practice had the potential to result in unmet care needs and negatively affect the delivery of care and services to Resident 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain complete medical records by failing to document a change of condition (COC - any significant improvement or decline in a resident's physical, mental or functional health) for one of three sampled residents (Resident 1). This deficient practice placed Resident 1 at risk of not receiving appropriate care due to incomplete resident medical care information. [...]

Inspectors wroteBased on interview and record review, the facility failed to assist and arrange transportation services for a follow-up neurosurgery (the medical specialty focused on diagnosing and treating disorders of the nervous system) specialist appointment as ordered by the physician for one of five sampled residents (Resident 1). This deficient practice had the potential to negatively affect the residents' continuity of care and treatment.

Inspectors wroteBased on interview and record review, the facility failed to follow the physician's order and ensure one of five sampled residents (Resident 1) was provided with a follow-up neurosurgery (the medical specialty focused on diagnosing and treating disorders of the nervous system) specialist appointment. This deficient practice had the potential to result in negative health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure that licensed nurses accurately assessed and completed Fall Risk Assessments for two of seven sampled residents (Resident 2 and Resident 3). This deficient practice had the potential to place the residents at increased risk for falls and fall-related injuries. a. During a review of Resident 2's admission Record, the admission Record indicated that the facility originally admitted Resident 2 on 4/1/2026 and readmitted the resident on 4/12/2026 with diagnoses that included pulmonary embolism (PE - a blood clot in the lungs), hypotension (low blood pressure), Guillain-Barre syndrome (GBS - a rare neurological disorder where your immune system mistakenly attacks the peripheral nerves that damage causes muscle weakness, numbness, and tingling), and history of falling. [...]

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure that the designated Director of Staff Development (DSD) was approved by the Department (from the State) to serve in the role of nursing home DSD. 2. Develop and implement policy and procedures (P&P) requiring the initiation and completion of former employment reference checks for prospective employees prior to hire. These deficient practices resulted in Licensed Vocational Nurse 1 (LVN 1) providing employee orientation and in-service training without the Department's approval and allowed the facility to hire new employees without completing verification of former employment references prior to hire.1. During a review of the facility's Nurse Assistant Training Program Notice (NATPN) approved by the Department, the NATPN indicated the following: The program expiration date was 9/30/2026. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedures (P&P), titled Abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment, resulting in physical harm, pain, or mental anguish), Neglect (failure of staff to provide necessary care) and Exploitation (illegal or improper act of using a resident's funds, property, or assets for another person's profit or advantage, often involving coercion, manipulation, or fraud) by failing to conduct required pre-employment screening prior to hiring three of six sampled employees (two Licensed Vocational Nurses [LVN 1 and LVN 4] and the Director of Staff Development [DSD]). This deficient practice had the potential to place the residents at risk for elder abuse, neglect, and exploitation.a. [...]

Inspectors wroteBased on interview and record review the facility failed to provide the needed resident-centered (an approach that puts the individual's needs, preferences and well-being at the heart of their care plan) care and services for one of three sampled residents (Resident 2). The facility did not notify Resident 2's physician after the resident refused scheduled insulin (an essential hormone that regulates blood sugar) administration on 5/12/2026; 5/13/2026; 5/14/2026; 5/16/2026; 5/17/2026; 5/18/2026; 5/19/2026. This deficient practice had the potential to result in unclear or inconsistent direction in the resident's plan of care and may have placed Resident 2 at risk for not receiving appropriate assessment and intervention related to repeated insulin refusals. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a written course of action that helps a resident achieve outcomes that improve their quality of life) for one of three sampled residents (Resident 1), who has a history of Post Traumatic Stress Disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event). This deficient practice had the potential to negatively affect the delivery of care and services to Resident 1. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 12/17/2025 with diagnoses that included PTSD. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure trauma (refers to an emotional, psychological, or physical response to a deeply distressing or disturbing event that overwhelms a resident's ability to cope) informed care was provided for one of three sampled residents (Resident 1) by: 1. Failing to ensure Resident 1 was seen and evaluated by the psychologist (a healthcare professional who specializes in studying the human mind, behavior, and emotions) as ordered by the physician. This deficient practice had the potential to result in a delayed identification and assessment of underlying trauma-related issues, resulting in missed opportunities for timely interventions, appropriate referrals, and individualized care planning. Resident outcomes and overall quality of care could be adversely affected. 2. Failing to assess and identify Resident 1's trauma triggers. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that therapy-recommended durable medical equipment (DME- medical equipment a person uses at home to help with safety, mobility, or daily care) was arranged prior to discharge for one of three sampled residents (Resident 1). This deficient practice had the potential to result in an unsafe discharge and placed Resident 1 at risk for falls, decreased mobility (ability to move around safely and easily), inability to safely perform activities of daily living (refers to the basic, routine self-care tasks a person performs to survive and function independently) and possible rehospitalization following discharge. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its Resident and Family Grievance policy by failing to document and log grievances and failed to implement its Theft and Loss policy by failing to complete a theft and loss report for one of five sampled residents. (Resident 1)These deficient practices had the potential to impede the facility's ability to investigate, address, and resolve resident concerns, and had the potential to violate residents' rights regarding the reporting and resolution of grievances, theft and loss allegations. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS- a resident assessment tool) for one of five sampled residents (Resident 3) was accurately coded, as evidenced by Resident 3's MDS reflecting that Resident 3 was receiving parenteral (a method of delivering essential nutrients directly into a patient's bloodstream intravenously [IV-through a vein], completely bypassing the digestive tract) or IV feeding. However, there was no clinical documentation indicating that Resident 3 required parenteral or IV nutritional support. This deficient practice resulted in an inaccurate assessment of Resident 3's MDS Section K (which evaluates a resident's swallowing ability and nutritional status), thereby compromising the accuracy of the resident's documented nutritional and feeding status. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1) received care and services in accordance with professional standards of practice by failing to administer Resident 1's prescribed Insulin Lispro (a fast-acting form of insulin [an essential hormone produced by the pancreas that regulates the amount of sugar in the blood]), as ordered by the physician. This deficient practice resulted in the improper administration of lispro insulin and had the potential to place the resident at risk for hyperglycemia (high blood sugar, occurring when there is too much sugar in the bloodstream because the body lacks or cannot effectively use insulin). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of five sampled residents (Resident 4) received meals that accommodated the resident's food preferences. This deficient practice resulted in Resident 4's food preferences not being honored and had the potential to result in decreased nutritional intake which could place the resident at risk for weight loss and malnutrition (lack of sufficient nutrients in the body). [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate and complete medical records in accordance with accepted professional standards and practices for two of five sampled residents (Resident 1 and Resident 5), by failing to ensure Registered Nurse Supervisors completed the facility's Clinical Admission assessment documentation upon admission. This deficient practice had the potential to affect the development and implementation of appropriate plan of care for Resident 1 and Resident 5 due to incomplete admission assessment documentation. a. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to remain free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of three sampled residents (Resident 1), when on 4/16/2026, Resident 2 punched Resident 1 in the face several times with a closed fist (a person's hand when the fingers are bent in toward the palm and held there tightly). This deficient practice resulted in Resident 1 being subjected to physical abuse by Resident 2 while under the care and supervision of the facility. Resident 1 sustained a loose tooth and bleeding gums. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that the attending physician (AP 1) provided a History and Physical (H&P- medical evaluation consisting of a detailed resident interview regarding their health history and a structured physical assessment) note following the initial visit for one (1) of three (3) sampled residents (Resident 2). This deficient practice had the potential to negatively affect the delivery of care and services for Resident 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a call light (a device used by a resident to signal his/her need for assistance from staff) was within a resident's reach while in bed for one of three sampled residents (Resident 2). This deficient practice had the potential to delay the provision of services and residents' needs not being met.

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan (a document designed to facilitate communication among members of the care team that summarizes a resident's health conditions, specific care needs, and current treatments) within 48 hours of a resident`s admission to the facility to reflect the immediate needs that included interventions to address congestive heart failure (CHF- a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) for one of three sampled residents (Resident 1). This deficient practice placed Resident 1 at risk for not having goals and interventions specific to Resident 1's diagnosis of CHF and had the potential to negatively affect the health and well-being of Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Certified Nursing Assistant 1 (CNA 1) provided two-person physical assistance when using a mechanical lift machine (a device used to move those who are unable to stand on their own or whose weight makes it unsafe to move or lift them manually) when adjusting a resident while on the shower chair for one of three sampled residents (Resident 3). This deficient practice had the potential for the resident to experience discomfort during transfer by a mechanical lift and may lead to accident such as a fall and injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure licensed nurses held (did not give) a resident's blood pressure (the force of blood pushing against the walls of the arteries) medications when the resident's blood pressure was outside of the physician's prescribed parameters (a set of defined limits) for one of three sampled residents (Resident 1). This deficient practice had the potential to place the resident at increased risk of experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention) from the medication.

Inspectors wroteBased on interview and record review the facility failed to ensure one of three sampled residents' (Resident 1), physician was notified of Resident 1's refusal of potassium chloride (medication used to prevent low blood potassium levels) and metoprolol succinate (a medication that lowers blood pressure and heart rate) for three or more consecutive doses. This failure had the potential to result in Resident 1 having decreased levels of potassium (a vital mineral and electrolyte necessary for nerve function and maintaining a regular heartbeat), increased blood pressure, and placed Resident 1 at risk for a decline in overall health status.

Inspectors wroteBased on interview and record review the facility failed to ensure one of three sampled residents (Resident 1) had weekly skin assessments completed in accordance with the facility's policy and procedure (P&P) titled Skin Assessment. This failure had the potential to result in the delay of identification and timely intervention of skin breakdown and pressure injuries (also known as pressure sores and decubitus ulcers, localized damage to the skin and/or underlying tissue caused by prolonged pressure or friction, often over bony areas) and placed Resident 1 at risk for a decline in overall health status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled resident's (Resident 1) care plans (a document that summarizes a resident's needs, goals, and care/treatment) were implemented by failing to place Resident 1's hearing aids (a small electronic medical device to assist with hearing loss) and eyeglasses on Resident 1 while Resident 1 was out of bed as indicated in the care plan. This deficient practice had the potential to not meet the resident's medical needs and maintain the resident's highest practicable physical, mental and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to provide a durable medical equipment (DME- an equipment that is used for a medical reason) to one of four sampled residents (Resident 1) by failing to provide Resident 1 a recliner wheelchair following Physical Therapist 1's (PT 1) recommendation on 12/26/2025 due to the resident's poor sitting balance and left upper extremity (limb of a body, such as an arm or a leg) non weight bearing (to not put any weight at all on a specific body part, usually a leg or foot). This deficient practice resulted in a delay in providing the recommended DME, which had the potential to cause a decline in the resident's functional status and increase the risk of injury.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a written course of action that helps a resident achieve outcomes that improve their quality of life) for one of three sampled residents (Resident 1), that addressed Resident 1's history of post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event). This deficient practice had the potential to negatively affect the delivery of care and services to Resident 1. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 2/21/2024 with diagnoses that included 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 provide resident centered behavioral services for one of three sampled residents (Resident 1), who has a history of post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event). This deficient practice had the potential to result in Resident 1 not receiving the appropriate treatment and services to correct the assessed behavior or to attain the highest practicable mental and psychosocial well-being. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 2/21/2024 with diagnoses that included 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 ensure one of six sampled residents (Resident 8), who did not have the capacity to understand and make decisions, had their representative e-sign (a legally binding way to sign digital document electronically, replacing handwritten signature) the resident's admission Packet. On 5/13/2025, admission Assistant 2 (ADA 2) had Resident 8's admission Packet e-signed by Resident 8 and not the resident's representative. This deficient practice violated the resident's and their representative's right and had the potential to place Resident 8 at risk of making health care decisions he could not understand that may affect their health conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain room temperatures within the required range of 71 degrees Fahrenheit ( F - a scale of temperature) to 81 F for one of three sampled residents (Resident 1) room and in the facility's lobby areas. This deficient practice violated residents' rights to a comfortable, homelike environment and had the potential to adversely affect their quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices during a Coronavirus Disease 2019 (COVID-19 - a highly contagious respiratory illness in humans capable of producing severe symptoms caused by the SARS-CoV-2 virus) outbreak (OB - when more people than usual get sick with a particular disease in a specific area over a certain time period) by:1. Failing to ensure two of 13 sampled staff (Activity Assistant 1 [AA 1] and Certified Occupational Therapy Assistant 1 [COTA 1]) wore masks properly, covering both nose and mouth while in resident care areas2. Failing to ensure two of 13 sampled staff (Physical Therapist 1 [PT 1] and Housekeeping 1 [HK 1] performed hand hygiene (HH - cleaning hands by either washing with soap and water, or by using a hand sanitizing [removing germs] gel) when:a. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure three of three residents (Resident 1, 2 and 3) were provided with a discharge summary that included recapitulation (Recap - describes the resident's course of treatment while residing in the facility) of the residents' stay and complete, appropriate discharge information and instructions to ensure safe and orderly discharge from the facility. This deficient practice had the potential to result in unsafe discharge, incomplete documentation of the resident's transfer or discharge in the resident's medical record, and inadequate communication of necessary discharge information to the resident or their representative.a. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide medically related social services (services provided by the facility's staff to assist residents in attaining or maintaining their mental and psychosocial health) to maintain the highest practicable psychosocial well-being for one of three sampled residents (Resident 1) when the social services department did not arrange home health services (HH) and provide a walker to Resident 1 upon discharge. This deficient practice had the potential to negatively affect the resident's continuity of care and safety during the transition from facility to home.

Inspectors wroteBased on interview and record review, the facility failed to ensure the licensed nurses documented the administration of Norvasc (a medication used to treat high blood pressure) and metoprolol tartrate (a medication used to treat high blood pressure) on the Medication Administration Record (MAR- a report detailing the medications administered to a resident by a healthcare professional) after administering the medications to one of two sampled resident (Resident 1). This deficient practice had the potential to result in medication errors and confusion regarding the delivery of care and services. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide laboratory services in a timely manner as ordered by a nurse practitioner (NP - a registered nurse with advanced training who can diagnose illnesses, prescribe medications, and manage patient care, often acting as a primary care provider) for one of three sampled residents (Resident 1). This deficient practice had the potential to delay necessary treatment and services to Resident 1.

Inspectors wroteBased on interview and record review the facility failed to: 1. Promote the resident's right to be informed of and participate in his treatment for one of one (Resident 48) sampled residents by failing to obtain an informed consent (comprehensive explanation of the treatment) and inform the resident or responsible party in advance of the risks and benefits of the psychotropic (medications that affect a person's state or behavior) medication Zyprexa (used to treat several mental health conditions). This deficient practice violated Resident 48's or his/her responsible party the right to make an informed decision regarding the use of a psychotropic medication. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide active range of motion ([AROM] performance of ROM of a joint without any assistance or effort of another person) exercises to both arms to one of five residents (Resident 77) with limited range of motion ([ROM] full movement potential of a joint) and mobility (ability to move) concerns in accordance with the Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) Discharge recommendations on 1/16/2025. This failure had the potential for Resident 77 to experience a decline in range of motion ([ROM] full movement potential of a joint) in both arms.

Inspectors wroteBased on interview, and record review, the facility failed to: 1. Ensure shower room two was free of accidents hazards when a broken shower head was leaking water, and a shower drain was not draining and filled the shower with about 2 inches of cloudy water. These deficient practices placed residents and staff that used shower room two at increased risk for slips, falls and injuries. 2. Implement its policy and procedure titled Fall Risk Assessment, for one of three sampled residents (Resident 137) by failing to complete an accurate fall risk assessment after the resident`s fall on 5/24/2025. This deficient practice placed Resident 137 at increased risk for recurrent falls and injuries. 3. [...]

Inspectors wrote2.a. During a review of Resident 89's admission Record, the admission Record indicated the facility admitted the resident on 5/02/2025 with diagnoses that included depression (feelings of sadness) and cerebrovascular accident (CVA, stroke, loss of blood flow to a part of the brain). During a review of Resident 89' s Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 5/08/2025, the MDS indicated Resident 89 was moderately impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 89 required supervision or touching assistance (helper provides verbal cues and/or touching as resident completes activity) with eating, oral hygiene, and personal hygiene. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%). Two (2) medication errors out of 27 total opportunities contributed to an overall medication error rate of 7.41% affecting two (2) of four (4) residents observed for medication administration (Resident 23 and 100). The medication errors were as follows: 1. Resident 23 did not receive ergocalciferol (a supplement used to treat vitamin D deficiency in patient with chronic kidney disease (CKD - a condition where the kidneys [organ that filters waste] are damaged) as ordered by Resident 23's physician. 2. Resident 100 received calcium with vitamin D3 (a combination medication used as a dietary supplement to provide support to bones) at a different time than ordered by Resident 100's physician. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to not leave six (6) medications on medication cart unattended, for one (1) of four (4) residents observed for medication administration (Resident 100). As a result, the facility failed to maintain safe and secure medication storage limited to authorized personnel. This deficient practice increased the risk that residents in the facility could have access to medications due to improper storage, possibly resulting in residents experiencing medication adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) affecting their health and well-being negatively.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure a resident's oxygen tubing (a flexible tube used to connect an oxygen source, like a concentrator or tank, to a delivery device, such as a nasal cannula [a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen] or mask) was labeled with the date of when it was last changed for one (Resident 98) out of five sampled residents investigated under the care area of infection control. This deficient practice had the potential to place the residents at increased risk of contracting an infection. 2. Ensure a resident's urinal (a container designed for collecting urine) was labeled with a resident identifier for one (Resident 138) out of five sampled residents investigated under the care area of infection control. [...]

Inspectors wroteBased on interview, and record review, the facility failed to provide care in a manner that maintained a resident's dignity when: 1. A resident's urinary catheter bag (device used to collect urine drained from the bladder via a urinary catheter [a hollow tube inserted into the bladder to drain or collect urine]) was not covered with a privacy bag (also known as a dignity bag - device used to cover the contents of a urinary catheter bag) for one of two sampled residents (Resident 137) reviewed under the dignity care area. 2. Staff failed to provide privacy and failed to consistently knock before entering a shower room for one of one sampled resident (Resident 119).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's call light (a device used in healthcare settings to allow patients or residents to signal for assistance from staff members) was within reach for one (Resident 138) out of one sampled resident. This deficient practice had the potential to result in the resident not being able to call for facility staff assistance and delay of provision of necessary care and services that can negatively affect the resident's comfort and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the primary physician of a significant change in condition (major decline or improvement in a resident's status that will not resolve itself without intervention) for one of five residents (Resident 119) with limited range of motion ([ROM] full movement potential of a joint) and mobility (ability to move) concerns by failing to report Resident 119's improvement in performing sit-to-stand transfers using both prosthetic (device designed to replace a missing part of the body or to make a part of the body work better) legs in accordance with Resident 119's care plan. This failure prevented Resident 119 from obtaining Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) services to improve independence with mobility, including the ability to walk.

Inspectors wrote2. During a review of Resident 577's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the facility admitted the resident on 5/22/2025 with diagnoses that included confirmed adult physical abuse (confirmed case that a resident suffered from physical abuse) and injury of the head. During a review of Resident 577' s Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 5/28/2025, the MDS indicated Resident 577 was moderately impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 577 required moderate/partial assistance with walking 50 feet. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Abuse, Neglect and Exploitation, for one of nine residents investigated under the abuse care area by not reporting to the California Department of Public Health (CDPH), the local Ombudsman (an advocate who supports residents by resolving issues related to their health, safety and well-being) the Local Law Enforcement (LLE), and the facility administrator, an allegation of verbal abuse by Resident 96 to Resident 46, immediately but no later than two hours after the allegation was made. This deficient practice resulted in unidentified abuse in the facility and failure to protect Resident 46 from further abuse. Cross reference to F600.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately assess the range of motion ([ROM] full movement potential of a joint) limitations for one of five residents (Resident 77) with limited ROM and mobility (ability to move) concerns. The facility failed to accurate assess Resident 77's left leg ROM limitation during three quarterly Minimum Data Set ([MDS] a federally mandated resident assessment tool) assessments on 9/24/2024, 12/18/2024, and 3/17/2025. This failure had the potential to affect the provision of Resident 77's care and provided inaccurate information to the Federal database.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Develop a care plan addressing a resident's oxygen therapy for one (Resident 32) out of two sampled residents investigated under the care area of respiratory care. 2. Develop a care plan addressing a resident's use of hydromorphone (opioid medication used to treat moderate to severe pain) for one (Resident 117) out of five sampled residents investigated under the care area of unnecessary meds, chemical restraints/psychotropic meds, and med regimen review. These deficient practices had the potential to result in failure to deliver the necessary care and services.

Inspectors wroteBased on interview and record review the facility failed to: 1. Update and revise a resident`s care plan (a document outlining a detailed approach to care customized to an individual resident's need) for indwelling catheter (a hollow tube inserted into the bladder to drain or collect urine) quarterly for one of one sampled resident (Resident 137). These deficient practices had the potential to result in inadequate care and complications related to catheter use. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to transfer one of five residents (Resident 89) with limited range of motion ([ROM] full movement potential of a joint) and mobility (ability to move) concerns out-of-bed and into the wheelchair from 5/23/2025 to 6/4/2025 (12 days) due to the absence of the left knee immobilizer (device worn on the knee to restrict its movement, often used after surgery or severe injury to help the knee heal and prevent further damage). This failure had the potential for Resident 89 to experience a decline in activities of daily living ([ADLs] routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) and mobility and resulted in Resident 89's feelings of sadness and depression.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident who required assistance with bathing and shower was provided care and services to maintain good personal hygiene for one of one sampled resident (Resident 57) investigated under Activities of Daily Living (ADLs- is a term used to collectively describe fundamental skills required to independently care for oneself, such as eating, bathing, and mobility). This deficient practice had the potential to negatively affect the resident's psychosocial well-being due to poor hygiene.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled resident (Resident 147) obtained vascular studies (tests that check he blood flow in your arteries and veins) and had a follow-up appointment with the vascular surgeon as ordered by the physician. This deficient practice had the potential to result in Resident 147 not receiving the care and services needed to treat his vascular health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's low air loss mattress (LAL - a specialized support surface designed to reduce pressure on the skin and prevent or manage pressure ulcers [localized damage to the skin and/or underlying tissue usually over a bony prominence]) was set to the correct setting for one (Resident 32) out of three sampled residents investigated under the care area of pressure ulcer/injury. This deficient practice had the potential to place the resident at increased risk for discomfort and development of pressure ulcers/injuries.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure one of two sampled residents (Resident 137) with an indwelling catheter (a hollow tube inserted into the bladder to drain or collect urine) received proper care and services by failing to provide indwelling catheter care to the resident since 5/12/2025. 2. Place Resident 164`s urinary catheter collection bag in a position below the level of his bladder while sitting on his wheelchair. These deficient practices had the potential to result in Resident 137 and 164 developing urinary tract infections (UTI-an infection in the bladder/urinary tract) and other health complications related to the use of an indwelling catheter.

Inspectors wroteBased on interview and record review, the facility failed to ensure nurses documented nonpharmacological interventions (healthcare strategies that aim to improve health and well-being without using medications) prior to administering as needed (PRN) hydromorphone (an opioid medication used to treat moderate to severe pain) to one (Resident 129) out of two sampled residents investigated under the care area of pain management. This deficient practice had the potential to place the resident at increased risk of experiencing adverse side effects such as drowsiness, constipation, and decrease in respiration.

Inspectors wroteBased on interview and record review the facility failed to document in the resident`s clinical record the physician`s order to discontinue hemodialysis treatment (HD- the removing of waste and excess fluid to prevent build up in the body for residents who have loss of kidney [organs that remove waste products from the blood and produce urine] function) and send the resident to vascular surgery for permcath (a specialized central venous catheter [CVC- used for long-term hemodialysis treatment]) removal for one of four residents (Resident 122) investigated under the care area of dialysis. This deficient practice had the potential to result in health complications, including the risk of infection at the permcath site.

Inspectors wroteBased on observation, interview, and record review, the facility failed to act upon recommendations from the Consultant Pharmacist (CP -a healthcare specialist who provides expert advice on medications and pharmaceutical services, including patient safety) for one of two sampled residents (Resident 144) investigated for unnecessary medications by failing to review all of Resident 144`s PRN (as needed) medications for constipation (a problem with passing stool) and to ensure that the physician`s orders state the sequence in which the medication should be administered. This deficient practice had the potential for Resident 144 to receive an unnecessary medication that can lead to adverse side effects (any unwanted or harmful effect of a drug or treatment).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Resident 89 received the medication Paxil (brand name and most used name for paroxetine, an antidepressant medication) from 5/31/2025 until 6/04/2025. Paxil is considered a significant medication. This deficient practice placed the resident at risk for experiencing side effects, including symptoms of depression.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) intervention to one of five sampled residents (Resident 119) with range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move) concerns who improved with sit-to-stand transfers and ambulation (the act of walking) using new prosthetic (device designed to replace a missing part of the body or to make a part of the body work better) legs in accordance with the facility's policies titled, Purpose and Objectives of Inpatient Rehabilitation Services and Provision of Quality Care. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for two of 48 sampled residents (Resident 137 and Resident 89) by failing to: 1. Develop a complete Change in Condition (COC- a sudden clinically important deviation from a resident's baseline in physical, cognitive, behavioral, or functional domains) Evaluation form after Resident 137's fall on 5/24/2025. This deficient practice placed Resident 137 at risk of not receiving appropriate care due to inaccurate medical care information and the potential to result in confusion in Resident 137's care and services. 2. Ensure a nursing wound treatment to Resident 89's left knee was not documented prior to the resident receiving the treatment. This deficient practice had the potential to result in missed wound care treatments.

Inspectors wroteBased on interview and record review the facility failed to ensure trauma (refers to an emotional, psychological, or physical response to a deeply distressing or disturbing event that overwhelms a resident's ability to cope) assessments were conducted for three of three sampled residents (Resident 1, Resident 2, and Resident 3). This deficient practice may result in delayed identification of underlying trauma-related issues, which could compromise resident care, delay appropriate referrals, and negatively impact resident outcomes.

Inspectors wroteBased on interview and record review the facility failed to document wound care treatment provided for one of three sampled residents (Resident 2) in the Treatment Administration Record (TAR-medical record indicating treatment provided to the resident). This deficient practice had the potential for inconsistent treatment as ordered by the physician, worsening of current pressure ulcer (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) and worsening skin condition.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a grievance filed by one of three sampled residents (Resident 1) was documented and filed in the facility grievance log. This deficient practice had the potential to affect the residents' quality of life and the provision of care.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident ' s right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm by one resident towards another) for one of three sampled residents (Resident 4) when on 10/17/2024 at around lunch time, Registered Nurse 2 (RN 2) witnessed Resident 5 punched Resident 4 with his (Resident 5) closed fist twice on the right side of face while Resident 4 was sitting on the wheelchair. This deficient practice resulted in Resident 4 being subjected to physical abuse by Resident 5 while under the care of the facility. [...]

Inspectors wroteBased on interview, and record review, the facility failed to implement its policy and procedure by failing to conduct a thorough investigation for an allegation of physical abuse (deliberately aggressive or violent behavior with the intention to cause harm by one resident towards another) for two of three sampled residents (Resident 4 and Resident 5) when on 10/17/2024 at around lunch time, Registered Nurse 2 (RN 2) witnessed Resident 5 punched Resident 4 with his (Resident 5) closed fist twice on the right side of face while Resident 4 was sitting on the wheelchair. This deficient practice had the potential to place the residents at risk for further abuse and may lead to serious outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled staff members (Licensed Vocational Nurse 1 [LVN 1]) wore an identification badge while on duty. This deficient practice had the potential to limit the residents' right to know the names of staff who provide care while also preventing residents from identifying staff from visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights (a device used by a resident to signal his/her need for assistance from staff) were within a resident ' s reach while in bed for one of three sampled residents (Resident 2). This deficient practice had the potential to delay the provision of services and resident ' s needs not being met.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS- a federally mandated resident assessment tool) for one of three sampled residents (Resident 2), a Thai (a native or inhabitant from Thailand) resident, was accurately conducted by failing to utilize the facility provided translator service to conduct Resident 2 ' s MDS assessment. This deficient practice resulted in an inaccurate assessment of Resident 2 ' s MDS quarterly assessment Section C (section of the MDS assessment focusing on cognitive [relating to or involving the processes of thinking and reasoning] patterns).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a communication board (a visual tool that helps residents, their families, and the care team communicate) with the residents preferred language of Thai (Foreign language of Thailand) was provided to one of two sampled residents (Resident 2). The facility provided Resident 2 with a communication board in tagalog (foreign language of the Philippines) This deficient practice had the potential to result in failure of delivering the necessary care and services to Resident 2 and could lead to frustration for Resident 2 when trying to express their (Resident 2) needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one staff member (Licensed Vocational Nurse 1 [LVN 1]) did not wear personal protective equipment (PPE - equipment designed to protect the wearer from injury or the spread of illness or infection) in the hallway while pushing a resident on a wheelchair. This deficient practice had the potential for the spread of infection and cross contamination among residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a written document that summarizes a resident's needs, goals, and care/treatment) with resident-specific interventions for one of three sampled residents (Resident 1). Resident 1 is blind and raises and lowers his bed using the bed control and is unaware of the height of the bed. This deficient practice had the potential for a delay in care and services and placed Resident 1 at an increased risk of sustaining an injury from a fall.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) who was at risk for falls was not in bed in a high position and had an accurate fall risk assessment following a fall incident. This deficient practice placed Resident 1 at an increased risk of sustaining an injury from a fall.

Inspectors wroteBased on interview and record review, the facility failed to provide a specialized service for a resident with major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest) by failing to provide a psychiatry evaluation per the physician's order for one of four sampled residents (Resident 1). This deficient practice had the potential to negatively affect the resident's psychosocial (the mental, emotional, social, and spiritual effects of a disease) well-being and delay in attaining the resident's highest practicable mental and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of 23 sampled residents (Resident 139) was kept free from accident and failed to provide a safe environment free from accident hazards (elements of the resident environment that have the potential to cause injury or illness) for the residents, staff, and visitors, as indicated in the facility's policies and procedures by: 1. Failing to identify that one of 23 sampled residents (Resident 139) had a torch lighter (a device that creates a flame that is hotter [reaching 2,500 degrees Fahrenheit {°F- a unit of measure}] and more intense than a soft flame lighter (a device that procedures a small, soft, yellow flame reaching temperatures of 1400 °F, that is not as powerful as a torch flame) in possession while admitted in the facility. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide dignity to residents by failing to: 1. Ensure staff members knocked and asked permission prior to entering the resident's room for two of three sampled residents (Resident 77 and 87). 2. Ensure an indwelling urinary catheter (a flexible tube inserted into the bladder and left in place to continuously drain urine) collection bag (attached to the catheter tube for the purpose of collecting urine) was covered with a privacy bag (dignity bag- a bag that conceals urine in the collection bag) for one of two sampled residents (Resident 368). These deficient practices had the potential to affect the residents' sense of self-worth and self-esteem.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure that a medication, Vancomycin (an antibiotic used to treat infections caused by bacteria), was stored properly in the refrigerator for one of one sampled resident (Resident 43) during the inspection of one of five sampled medication carts (Medication Cart A). This deficient practice had the potential for Resident 43 to receive ineffective medication during administration due to a decrease of medication strength and stability. 2. Ensure that all drugs and biologicals used in the facility were labeled in accordance with professional standards by failing to label a box of artificial tears (eye drops that moisten dry eyes) with a resident's name for one of one sampled resident (Resident 121) but instead used a room number during the inspection of two of five sampled medication carts (Medication Cart B). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a copy of the resident's Advance Directive (AD-a written statement of a person's wishes regarding medical treatment) is kept in the resident's chart and easily retrievable for one of four sampled residents (Resident 99). This deficient practice had the potential to create confusion which could lead to conflict with the resident's wishes regarding their health care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Certified Nurse Assistant 10 (CNA 10) provided privacy to one of three sampled residents (Resident 466) prior to rendering perineal care (washing and cleaning the private areas [genital and rectal areas of the body] of the resident). This deficient practice violated the resident's right to privacy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a homelike environment for two of two sampled residents (Resident 61 and Resident 466) by failing to: 1. Ensure Resident 61 had curtains that were not broken and provided comfortable lighting in Resident 61's room. 2. Ensure Resident 466 was provided with a window shade to provide comfortable lighting and temperatures. These deficient practices had the potential to affect the residents' rights to a safe, clean, comfortable, and homelike environment and put the residents at risk for physical discomfort.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a comprehensive person-centered care plan (a plan for an individual's specific health needs and desired health outcomes) for one of two sampled residents (Resident 63) by not providing the resident with bilateral (both sides) floormats (padding placed on the floor to help prevent injuries related to falls). This deficient practice resulted in a lack of delivery of care for Resident 63.

Inspectors wroteb. A review of Resident 21's admission Record indicated the facility admitted the resident on 9/30/2020 with diagnosis of chronic obstructive pulmonary disease (COPD - a common lung disease causing restricted airflow and breathing problems.) A review of Resident 21's History and Physical (a thorough assessment that a healthcare provider performs during a resident's initial visit), dated 4/4/2024, indicated Resident 21 had the capacity to understand and make decisions. A review of Resident 21's MDS, dated [DATE], indicated that Resident 21 needs supervision or touching assistance during personal hygiene. During a concurrent observation and interview on 6/25/2024 at 8:13 a.m., in Resident 21's room, observed both of Resident 21's fingernails to be long. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the low air loss mattress (LAL - a specialty bed that alternates pressure to help heal and prevent pressure ulcers [an injury that breaks down the skin and underlying tissue when an area of skin is placed under pressure]) was set correctly for two of 35 sampled residents (Resident 74 and 95). This deficient practice had the potential to increase the resident's risk of skin breakdown.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a resident received oxygen as ordered by the physician for one of one sampled resident (Resident 93). This deficient practice had the potential to cause complications associated with Resident 93 receiving more oxygen than needed.

Inspectors wroteBased on interview and record review the facility failed to complete a post-hemodialysis (HD, the removing of waste and excess fluid to prevent build up in the body for residents who have loss of kidney [organs that remove waste products from the blood and produce urine] function) assessment for one of one sampled resident (Resident 99). This deficient practice placed Resident 99 at risk for complications of dialysis such as redness at the dialysis access site (way to reach the blood for hemodialysis), edema (too much fluid trapped in the body's tissues), excessive bleeding, and a change in vital signs (clinical measurements that indicate the state of a patient's essential body functions).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staffing information of the actual hours worked by licensed and unlicensed nursing staffing directly responsible for resident care per shift was posted daily for two of two days on 6/28/2024 and on 6/29/2024. This deficient practice had the potential to keep residents and visitors unaware of the total number of staff and the actual hours worked by the staff in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure Licensed Vocational Nurse 1 (LVN 1) administered a resident's erythromycin (used to treat certain infections caused by bacteria) ointment in accordance with the physician's order for one of 35 sampled residents (Resident 87). This deficient practice had the potential to place the resident at increased risk of experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention) from the medication. 2. Ensure medications were documented after being administered for one of one sampled resident (Resident 10). This deficient practice had the potential to result in inaccurate documentation and Resident 10 receiving duplicate medication therapy, which could have caused harm to the resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure licensed nurses monitored for side effects for a resident on an anticoagulant (medicines that prevent blood clots [gel-like clumps of blood] from forming in the blood vessels and heart) for one of 35 sampled residents (Resident 73). This deficient practice had the potential to result in the resident experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention) from the anticoagulant.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper food handling and storage practices by failing to: 1. Ensure a box of blueberry pie and strawberry rhubarb pie found in the facility's refrigerator were labeled per the facility's policy. This deficient practice had the potential to place 159 out of 165 residents living in the facility at risk for foodborne illnesses (when contaminated food is consumed which causes an infection resulting illness). 2. Ensure an eight-ounce glass of milk at the resident's bedside was labeled with a date and time to ensure the milk does not become spoiled and accidentally ingested for one of one sampled resident (Resident 65). This deficient practice had the potential to result in food borne illness upon ingestion of a spoiled milk.

Inspectors wroteBased on observation, interview and record review facility failed to maintain complete and accurate medical records by failing to document the administration of oxygen for one of one sampled resident (Resident 93). This deficient practice had the potential to negatively impact an accurate evaluation of the resident's progression or regression of the delivery of care services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's urinal (a container used to collect urine) was labeled with a resident identifier for one of 35 sampled residents (Resident 159). This deficient practice had the potential to increase the risk of spreading infection amongst residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a neurology (part of medicine that focuses on the brain and nervous system [spine and nerves]) appointment was rescheduled for one of three sampled residents (Resident 1). This deficient practice resulted in a delay in the delivery of care and services needed for Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices by failing to ensure a resident ' s nasal cannula (or nasal prongs, a device used to deliver extra oxygen through a tube and into a resident ' s nose placed directly on a resident ' s nostrils) was labeled with the date it was last changed for one of five sampled residents (Resident 1). This deficient practice had the potential to cause contamination of the resident ' s oxygen equipment and risk of transmission of bacteria that can lead to infections and respiratory distress.

Inspectors wroteBased on interview and record review, the facility failed to implement infection control practices by: 1. Failing to initiate (start) any tuberculosis (TB - a disease caused by germs that are spread from person to person through the air, and TB usually affects the lungs, but it can also affect other parts of the body, such as the brain, the kidneys, or the spine [back bone]) precautions after one of six sampled residents (Resident 1) was suspected for possible pulmonary (relating to the lungs) TB infection on 3/19/2024. 2. Failing to conduct an annual (yearly) TB tests for one of six sampled residents (Resident 2). This deficient practice had the potential to result in the spread of the TB disease to other residents, staff, and the public.

Inspectors wroteBased on interview and record review the facility failed to provide one of three sampled residents (Resident 2) a written notification of a room change prior to the move and the reason for the room change as per facility ' s policy and procedure (P&P) tilted, Change of Room or Roommate. On 3/20/2024, Resident 2 was moved to a different room without providing him with a written notice that included the reason for the move. This deficient practice resulted in Resident 2 to be confused about the room change and was denied the opportunity to inquire about the move.

Inspectors wroteBased on interview and record review the facility failed to develop a plan of care in consultation with the resident and /or the resident's representative for one of three sampled residents (Resident 1) as per the facility ' s policy and procedure (P&P) titled, Comprehensive Care Plans. Resident 1 Responsible Party (RP) was not afforded the opportunity to participate in the initial care plan conference meeting. This deficient practice had the potential for Resident 1 ' s preferences and needs not being met and for the plan of care not to being individualized and resident specific.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a communication board or aide was provided at bedside to facilitate ease of communication and allow the resident to communicate their needs for one of two sampled residents (Resident 1) whose primary and preferred language was not English. This deficient practice had the potential to result in failure of delivering the necessary care and services to the resident and cause frustration for the resident when trying to express their needs.

Inspectors wroteBased on interview and record review, the facility failed to implement the facility's influenza vaccine (prevents infection from influenza [a common, sometimes deadly viral infection of the nose, throat, and lungs]) policy by failing to ensure a resident and/or the resident's responsible party was provided education regarding the influenza vaccine for one of three sampled residents (Resident 1). This deficient practice had the potential for Resident 1 and/or their responsible party to not be aware of the risks and benefits of the influenza vaccine.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a resident-centered plan of care for one of three sampled residents (Resident 2). Resident 2 ' s specific behavior manifestations were not included in the care plan and the interventions were not individualized to the manifested behavior. In addition, Resident 2 ' s diagnosis of bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) was not addressed in the plan of care for Resident 2. This deficient practice had the potential to result in inconsistent implementation of care and supervision of Resident 2 and had the potential for Resident 2 to harm himself and other residents.

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision for one of three sampled residents (Resident 2), which resulted in Resident 2 getting into Resident 1 ' s bed while Resident 1 was in bed. This deficient practice had the potential for harm to Resident 1 including, physical abuse, sexual abuse, physical injury, and psychosocial (emotional problems negatively affecting a person ' s health and quality of life) harm.

Inspectors wroteBased on interview, and record review, the facility failed to: 1. Ensure the physician ' s order regarding laboratory tests for basic metabolic panel (BMP-blood test that give a snapshot of the health of the kidney, blood sugar levels and electrolytes [essential part of how your body functions, affecting everything from hydration to how your heart beats]) and ammonia (blood test to check the liver) to be drawn (when a blood sample is obtained to conduct lab tests on) on 12/7/2023 was completed for one of two sampled residents (Resident 1). 2. Ensure that facility staff promptly notified the physician regarding a low level of potassium (mineral that is essential for all of the body's functions, helps your nerves, muscles heart to function well, and also helps move nutrients and waste around your body's cells) on 12/14/2023 for one of two sampled residents (Resident 1). 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of two sampled residents (Resident 1) was free from significant medication error (when a medication is administered to a resident not as prescribed and has the potential to jeopardize the health and safety of the resident) by failing to ensure Resident 1 was not administered a dose of furosemide (medication that helps treat high blood pressure) and spironolactone (medication that helps treat high blood pressure) with a physician ' s ordered parameter (a set of defined, measurable limits) to hold (do not give) the medication if the resident ' s systolic blood pressure (SBP- measures the pressure in your arteries when your heart beats, normal range is 80 to 120 millimeters of mercury [mmHg]) is less than 110 mmHg. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) received supervision to prevent accidents by licensed and non-licensed nursing staff not checking on the assigned residents at the end and at the beginning of their nursing shift. On 10/25/2023 at 9:31 p.m., Resident 1, who was alert and oriented, left the facility without informing anyone and the nurses only learned about the missing resident at 3:45 a.m. on 10/26/2023, 5.5 hours after Resident 1 ' s departure, when General Acute Care Hospital 1 (GACH 1) called the facility about admitting Resident 1 to the emergency room (ER).

Inspectors wroteBased on interview and record reviewed, the facility failed to maintain complete and accurate medical records for one of three sampled residents (Resident 1), when Licensed Vocational 1 (LVN 1) falsely documented measuring Resident 1 ' s vital signs(clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions) during the 11 p.m. to 7 a.m. nursing shift on the night of 10/25/2023 to the morning of 10/26/2023 when Resident 1 was absent from the facility. This deficient practice has the potential to result in confusion regarding Resident 1 ' s condition and did not accurately reflect the services provided to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed for four of nine sampled residents (Residents 4, Resident 5, Resident 6, and Resident 7), to immediately report an outbreak (more cases of a disease than expected in a specific location over a specific time period) of the communicable disease (an infection transmissible by direct contact with an affected individual or the individual's body fluids or by indirect means), Influenza (a highly contagious viral infection that attacks the respiratory system [throat, nose, and lungs]) to comply with state and local public health authority requirements. The facility failed to report the Influenza outbreak to the State Survey Agency (SSA, the California Department of Public Health [CDPH] Licensing and Certification [L&C] District Office). [...]

Inspectors wroteBased on interview and record review, the facility failed to rightfully inform in advance of the risks and benefits of the proposed plan for the administration of a new psychotropic medication (medication that affects brain activities to control behavior or treat disordered thought processes) Trileptal (a medication used to treat seizures [sudden and uncontrolled body movements] and as mood stabilizer) and decreased Trazodone (a medication used to treat major depressive disorder [a mood disorder that involves a persistent feeling of sadness and loss of pleasure or interest in activities for long periods of time) for one of two sampled residents (Resident 1). [...]

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 five sampled resident ' s (Resident 4) dignity urinary drain bag (a bag that restores the dignity of catheterized [when a tube is placed into a resident ' s bladder to allow for urine to pass] residents by concealing urinary drainage bags from public view)was not touching the floor. This deficient practice had the potential to result in a urinary tract infection (an infection in any part of the urinary system includes the kidneys, ureters, bladder, and urethral) that can cause serious health problems such as sepsis (a serious condition in which the body responds improperly to an infection and a potentially life-threatening complication).

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection prevention and control practices for one of six sampled residents (Resident 1) when the facility staff failed to ensure that Resident 1 ' s nasal cannula tubing (a medical device to provide extra oxygen therapy to people who have lower oxygen levels) was not touching the floor. This deficient practice had the potential to increase the risk of infection from contamination (bacteria or other microorganisms are unintentionally transferred from one substance or object to another with harmful effect).