The Springs Post-Acute

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain resident confidentiality when Respiratory Therapist (RT) 1 left the computer with the electronic health record (EHR) open and a clipboard with notes containing a list of resident names fully exposed and unattended in the facility hallway. This deficient practice violated the residents' right to privacy and confidentiality.

Inspectors wroteBased on observation, interview, and record review, the facility did not meet standards of quality when licensed staff failed to follow or clarify physician medication orders for three of three residents (Residents 54, 97, and 76):1. For Resident 54, facility failed to separate the administration of Ferrous Sulfate and Minocycline to prevent medication interactions.2. For Residents 54, 97, and 76 facility failed ensure enteral feeding was ordered held before and after administration of phenytoin via gastrostomy tube. This deficient practice had the potential for medication or food interactions which could result in decrease in antibiotic effectiveness for Resident 54 and for Residents 54, 97, and 76 potential to result in seizure activity, decline in resident's condition, or hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services to improve or maintain range of motion (ROM, full movement potential of a joint) for one of six sampled residents (Residents 44) with ROM and mobility (ability to move) concerns by failing to: 1. Ensure Restorative Nursing Aide (nursing aide program that helps residents maintain any progress made after therapy intervention to maintain their function) 1 (RNA 1) provided passive range of motion (PROM, movement at a given joint with full assistance from another person) exercises to Resident 44's both wrists and hands and applied splints (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) to Resident 44's both hands in accordance with physician's orders.2. [...]

Inspectors wroteCross Reference to F688 Based on observation, interview, and record review, the facility failed to ensure Restorative Nursing Aide (nursing aide program that helps residents maintain any progress made after therapy intervention to maintain their function) 1 (RNA 1) was competent to provide RNA services to one of six sampled residents (Resident 44) by failing to ensure RNA 1 was competent to correctly identify and apply hand roll splints (device or apparatus used to support and immobilize a broken bone or impaired joint) to Resident 44's both hands in accordance with physician's orders and was qualified to modify the RNA splinting program. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication administration and accurate accountability of all controlled medications (medications with a high potential for abuse) for three of seven sampled residents (Resident 30, 50, and 58) reviewed during controlled medication storage inspection by failing to:A. Document the removal of Oxycodone with Acetaminophen (a pain medication combining oxycodone, an opioid, and acetaminophen, a non-opioid analgesic) for administration to Resident 30 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]). B. [...]

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 drug interactions, for three of seven sampled residents (Residents 54, 97, and 76). 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 Residents 54, 97, and 76.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the medication error rate was less than five percent (%, unit of measurement). The facility had four medication errors out of a total of twenty-five opportunities resulting in an overall medication error rate of 16 %, affecting one of six residents (resident 54) observed during medication administration (pass). The medication errors noted for Resident 54 were as follows:1. Facility failed to separate and check compatibility (the ability to combine two medicines without interfering with the action of either) between Minocycline (antibiotic) and Ferrous Sulfate (iron supplement) before administering the two medications together via gastrostomy tube (g-tube: a feeding tube that's surgically placed into the stomach).2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of three residents (Resident 54, 97, and 76) were free of a significant medication error (any preventable error in medication administration that can result in resident discomfort, jeopardizing health and safety, or requiring medical intervention) by failing to:1. Ensure Resident 54 was not administered interacting medications, Ferrous Sulfate and Minocycline together for 18 days, between 4/5/2026 through 4/22/20262. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to establish and maintain an implementation for prevention and control program (IPCP) to maintain safety and sanitary for two out of two sampled residents by failing to: Report an outbreak of scabies (a contagious skin condition caused by tiny insects called mites that infest and irritate your skin by intense itching, inflammation, and red patches) to the local health Department after 2 residents (Residents 66 and Resident 87) had rashes with severe itching and tested positive for skin scraping (a quick, minimally invasive diagnostic procedure used to sample the outer layer of skin, usually with a scalpel blade, to detect fungal infections (using [NAME]) or parasites like scabies/mites (using mineral oil) under a microscope. for scabies, which affected their quality of life, while being treated for suspected scabies. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure reasonable accommodation of resident needs when staff did not respond in a timely manner to gastrostomy tube (GT-a tube surgically inserted into the stomach to allow access for nutrition, fluids, and medications) alarms for 2 of 8 sampled residents (Residents 56 and 74). This deficient practice resulted in the potential for the GT pump to become dislodged or for the tube to slip out of proper position, causing incorrect or delayed delivery of the required volume (Resident 74).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 67) was assessed and monitored properly for the use of hand mittens (padded, mitt-shaped devices designed to prevent patients from pulling at tubes or self-injury). This deficient practice had the potential to place Resident 67 in unnecessary restraints.

Inspectors wroteBased on interview and record review the facility failed to ensure one of five sampled residents (Resident 8) received non pharmacological interventions (evidence-based, non-invasive, non-drug treatments aimed at improving, maintaining, or modifying health conditions) prior to the administration of PRN (given as needed or requested) Ativan (a medication used to treat anxiety-feelings of fear, dread, or uneasiness). This deficient practice had the potential to result in resident's unnecessary consumption of medications and cause untoward adverse reactions for taking psychotropic (drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one resident (Resident 88) received daily activities appropriate to the resident's needs. The deficient practice had the potential to negatively affect the residents' physical and mental well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 41) who was assessed as being at very high risk for pressure ulcer (a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear) development was provided a pressure relieving barrier to be placed between Resident 41's overlapping, contracted (loss of motion of a joint associated with stiffness and joint deformity) toes of the left foot as indicated per facility policy. This deficient practice had the potential to result in Resident 41 developing pressure ulcers on the left foot.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident with a physician order for a foley catheter (also called indwelling catheter, a thin, flexible tube that drains urine from the bladder into a bag outside the body) and had monitoring and care provided to prevent recurrent urinary tract infection ([UTI], a bacterial infection that affects the urinary tract, which includes the bladder, ureters, and kidneys) for one of two sampled residents (Resident 94). This deficient practice had the potential to result in Resident 94 acquiring recurrent UTIs when foley catheter was not monitored and care was not provided according to the physician's order.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one hemodialysis ([HD]a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) residents (Resident 10) received HD on 1/27/2026. This deficient practice had the potential to result in fluid overload (a condition where excessive water and sodium accumulate in the body) weight gain, edema (swelling in legs/arms), and shortness of breath.

Inspectors wroteBased on observation and interview, the facility failed to ensure a thermometer was placed in the dry storage food area. This deficient practice had the potential to result in food-borne illnesses (food poisoning) of the residents with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea and fever and can lead to other serious medical complications and hospitalization. During a concurrent observation and interview on 4/20/2025 at 9:08 a.m. with the Dietary Manager (DM), the DM verbalized the current storage room temperature is 72 degrees Fahrenheit ( F, temperature scale). The DM stated the facility did not need to have a thermometer in the dry storage room and indicated that when the room gets too hot, they will put the thermometer in the dry storage room and take the temperature. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure exterior waste disposal containers were fully closed and trash collection area was cleaned and free of black sticky residue. This failure had the potential to result in the attraction of pests and spread of pathogens due to unsanitary environment.

Inspectors wroteBased on interview and record review, the facility failed to ensure the General Acute Care Hospital (GACH) Discharge Summary for one of six sampled residents (Resident 3) was in the medical record and readily accessible. This deficient practice had the potential to delay and negatively affect the delivery of necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two hospice (compassionate care for people who are near the end of life) residents (Resident 13) home health aide ([HHA] trained professional who provides in-home personal care, basic health monitoring, and companionship to elderly, disabled, or chronically ill individuals) visits were made twice a week. The deficient practice had the potential to result in negative health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure one out of four sampled residents (Resident 31) was screened appropriately prior to initiating antibiotic treatment. This deficient practice had the potential to increase antibiotic resistance and provide antibiotics without justification. During a review of Resident 31's admission Record, the admission Record indicated Resident 31 was admitted to the facility on [DATE] with diagnoses including tracheostomy (a tube placed into a surgically created hole through the front of the neck and into the windpipe-trachea), gastrostomy (G-tube, a tube placed directly into the stomach for long-term feeding), and acute and chronic respiratory failure. During a review of Resident 31's history and physical (H&P) dated 6/13/2025, the H&P indicated Resident 31 had fluctuating capacity to understand and make decisions. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Responsible Party (RP) 1 was notified when Resident 1 was started on Lantus ([insulin glargine] medication used to manage high blood sugar levels for people with diabetes mellitus [DM - a disorder characterized by difficulty in blood sugar control and poor wound healing]) for one of three sampled residents (Resident 1) on 12/8/2025. This deficient practice resulted in the violation of Resident 1's RP 1 rights to be informed and involved in treatment decisions which could lead to distrust toward the facility and its practices.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control measures to prevent a scabies (a contagious skin condition caused by tiny insects called mites which infest and irritate the skin causing intense itching, red patches, and inflammation [the immune system's response to harmful stimuli]) outbreak (two or more clinically suspect or confirmed cases of scabies identified in patients/residents, healthcare workers, volunteers and/or visitors during a six week time period) for five of five sampled residents (Resident 1, 2, 3, 4, and 5) by failing to:1. Recognize a possible scabies outbreak when Residents' 1,2,3,4 and 5 with suspected scabies were treated prophylactically (a medication or action used to prevent disease or a recurrence of a condition) by the physician for scabies. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the physician of a significant change in condition (COC sudden, clinical deviation from a resident's baseline in physical, cognitive, behavioral, or functional status) for one of three sampled residents (Resident 1) when the facility did not notify the physician when Resident 1 developed swelling and discoloration of the left fourth and fifth fingers. This failure had the potential to delay necessary medical evaluation and treatment, placing the resident at risk for worsening of the condition or other complications.

Inspectors wroteBased on interview and record review, the facility failed to report a fracture (broken bone) of unknown origin for one of two sampled residents (Resident 1 ) to the California Department of Public Health (CDPH), law enforcement, or the Ombudsman. This deficient practice resulted in a delay in initiating an investigation and potentially increased the risk of abuse, neglect or mistreatment of other residents. of an investigation and potentially increased the risk of abuse, neglect, and mistreatment of other residents.

Inspectors wroteBased on interview and record review the facility failed to protect one of three residents' (Resident 1) right to be treated with respect, kindness, and dignity when Certified Nurse Assistant (CNA)1 entered Resident 1's room, even after being banned from providing care to Resident 1. The deficient practice violated residents' rights and had the potential to result in negative psychological outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to supervise one of six sampled residents (Resident 1), who was assessed as a high risk for falls by: a. Ensuring staff familiarity with Resident 1 ' s routine when Resident 1 was moved to a new room with a new set of care givers. b. Implement Resident 1 ' s Interdisciplinary Team ([IDT]- refers to a team of different healthcare professionals who work together to create a personalized care plan for a patient)-Fall Progress Notes interventions that indicated: b.1. Not to leave Resident 1 in the wheelchair unattended. b.2. When Resident 1was up in a wheelchair, activity staff or nursing staff would either escort Resident 1 to the activity room or return Resident 1 to bed. b.3. If Resident 1 was in his wheelchair in his room, or the hallway activity staff would endorse to nursing staff. c. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident, who required two-person assistance (two staff members assisting the resident with care) for turning and repositioning in bed, was not turned and repositioned by one person and sustained an injury for one of ten sampled residents (Resident 1). The facility failed to: 1. Ensure a certified nursing assistant (CNA 1) did not turn and reposition Resident 1 by himself on 2/8/2025. 2. Ensure CNA 1 followed Resident 1's untitled Care Plan dated 10/2/2023, which indicated Resident 1 required two-person assistance with turning and repositioning and did not turn the resident without a second person assistance. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services to five of 13 sampled residents (Resident 76, 48, 61, 68, and 54) with limited range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move) by failing to: 1. Provide Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) services after identifying ROM impairments (unspecified) in both arms and indicating Resident 76 could benefit from skilled services (therapy services performed by licensed therapists and necessary to treat illness and injury) for contracture (a stiffening/shortening at any joint that reduces the joint's range of motion) prevention management during the OT Evaluation, dated 8/7/2024. 2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure three of four sampled residents (Residents 34, 45, and 82) call lights (device that allows residents to request assistance from nursing staff) were answered in a timely manner. This deficient practice resulted in a delay of care and services.

Inspectors wroteBased on interview and record review, the facility failed to protect one of three sampled residents (Resident 50) from physical and verbal abuse, by not separating Resident 50 from Resident 197 after a verbal altercation and Resident 197 threw a box of tissues at Resident 50. This deficient practice placed Resident 50 at risk for further abuse and had the potential to cause feelings of intimidation, neglect and not feeling safe in the facility which was considered the Residents' home.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure three of three resident's (Resident 80, 86, 296) Minimum data Set (MDS - a resident assessment tool), Section P - Restraints (any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body) and alarms, indicated Residents 80, 86, and 296 had restraints. This deficient practice resulted an inaccurate depiction of Resident 80, 86, and 296's current health status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food containers that are opened were labeled with an open date and use by date. This deficient practice had the potential to result in pathogen (germ) exposure to residents and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea and fever and can lead to other serious medical complications and hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to identify unresolved quality deficiencies, some of which had been cited on previous surveys, and ensure actions were developed and implemented to attempt to correct the deficiencies through the quality assessment and assurance (QAA) process as evidenced by the severity and number of deficiencies cited involving assessment, monitoring, and documentation of physical restraints(any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body), and accurate resident assessment with documentation. This failure had potential to result in the residents residing in the facility not receiving services and care they need.

Inspectors wroteBased on interview and record review, the facility failed to provide documented evidence of all employees screening, education, offering, and current Corona virus disease, COVID-19 (contagious infectious disease), vaccination (medications used to prevent diseases usually given by injection or by mouth) status. This failure had the potential to place staff and residents at risk for serious outcomes such as being hospitalized due to COVID-19.

Inspectors wroteBased on observation, interview, and record review: a) The facility failed to ensure one of one resident (Resident 80) had a call light the resident could use. b) The facility failed to ensure one of three sampled residents (Resident 30) had a working call light. This deficient practice resulted in a delay of care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess, monitor, and document the use of hand mittens (soft gloves that are designed to restrict the movement of one or both hands, and are used with patients who have removed essential lines or tubes on more than one occasion.) to prevent the residents from pulling out his gastrostomy tube ([G-tube]- a tube inserted through the abdomen that brings nutrition directly to the stomach) for one of six sampled residents (Resident 86). This failure had the potential to result in entrapment, skin injury, and compromised circulation for Resident 86's hands.

Inspectors wroteBased on interview and record review the facility failed to ensure two of three sampled resident's (Resident 11 and 33) Preadmission Screening and Resident Review (PASARR - a federal assessment requirement to help ensure that individuals who have a mental disorder -MD- are placed in facilities that can provide the appropriate care) screening was accurate. This deficient practice had the potential to result in inappropriate placement and unidentified specialized services for Resident 11 and 33.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement a comprehensive care plan for one of two sampled residents (Resident 296) who had bilateral (both) hand mittens. This deficient practice had the potential to negatively affect the quality of life and wellbeing for Resident 296 to prevent him from achieving his highest practical well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services to one of 13 sampled residents (Resident 76) with limited range of motion [(ROM) full movement potential of a joint (where two bones meet)] and mobility (ability to move) by failing to transfer Resident 76 out of the bed daily. This failure had the potential to result in Resident 76's decreased activity tolerance and to experience limited social interaction, affecting Resident 53's quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain a podiatry (foot doctor) consult after one of three sampled resident (Resident 8) was noted with a thickened toenail of the left hallux (big toe). This deficient practice resulted in a delay of needed foot care services and had the potential to contribute to a negative physical and psychosocial wellbeing of Resident 8.

Inspectors wroteBased on observation, interview and record review, the facility failed to monitor, assess, document and discontinue a peripheral intravenous (IV) hep lock (is an intravenous catheter that is threaded into a peripheral vein, flushed with saline, and capped off for later use) site when IV therapy was completed for one of three sampled residents (Resident 42). This failure had the potential to result in Resident 42's IV hep lock site to develop an infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of three sampled ventilator (a medical device to help support or replace breathing) dependent resident (Resident 40)'s Heat and Moisture Exchanger (HME - way to provide humidification to adult tracheostomy [a surgical procedure that creates an opening in the trachea or windpipe to provide an airway when the natural airway is blocked or compromised]residents) portion of the ventilator circuit (tubing that connects the ventilator to the resident) was changed as scheduled. The failure had the potential to result in harboring of microorganisms (germs) in the respiratory equipment which can cause infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide Speech Therapy (SLP, profession aimed in the prevention, assessment, and treatment of speech, language, communicative, and swallowing disorders) services to one of 13 sampled residents (Resident 76) with limited range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move) by failing to: 1. Provide SLP services to Resident 76 in accordance with the SLP Evaluation recommendations, dated 8/6/2024. 2. Provide a SLP Evaluation in accordance with Resident 76's physician orders, dated 1/23/2025. These failures had the potential to prevent Resident 76 from improving speech, cognition, and the ability to eat by mouth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two Physical Therapists (PT 1) had a current and active license to provide Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) treatment at the facility. This deficient practice resulted in PT 1 providing intervention to Resident 90 and had the potential for PT 1 to provide intervention to other residents requiring PT treatment with an invalid PT license.

Inspectors wroteBased on, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 29) was offered the pneumococcal vaccine (a vaccination that protects against pneumococcal bacteria, which can cause serious infections such as pneumonia, meningitis, and sepsis) upon admission to the facility. This deficient practice had the potential to increase the risk of Resident 29 acquiring, transmitting, or experiencing complications from the pneumococcal disease.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician when a resident experienced a change of condition ([COC] a sudden, clinically important deviation from a patient's baseline in physical, cognitive [ability to think, understand, learn, and remember], behavioral, or functional status) for one of three sampled residents (Resident 1) when Resident 1 had a temperature of 103.8 degrees Fahrenheit (°F-unit of measurement [normal body temperature can range from 97°F to 99°F ]), heart rate (HR) of 130 beats per minute ( bpm normal resting heart rate is between 60 and 100 beats per minute) on [DATE] at 11:43 p.m., and hematuria ( blood in the urine) that started on [DATE]. The facility failed to: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents, with a change in condition (COC- a sudden, clinically important deviation from a patient's baseline [a minimum or starting point used for comparisons] in physical, cognitive (ability to think, understand, learn, and remember) behavioral, or functional status which without immediate intervention, may result in complications or death) manifested by temperature of 103.8 degrees Fahrenheit (°F-unit of measurement [normal body temperature can range from 97°F to 99°F ]), heart rate of 130 beats per minute ( bpm normal resting heart rate is between 60 and 100 beats per minute), hematuria ( blood in the urine) was transferred to a general acute care hospital (GACH) without a delay for one of three sampled residents (Resident 1). The facility failed to: 1. [...]

Inspectors wroteBased on interview and record review, the facility staff failed to ensure funds were returned to social security after a resident was discharged from the facility for one of three sampled residents (Resident 1). This deficient practice resulted in the Business Office Manager (BOM) not refunding social security funds back within three business days as indicated per the facility ' s Policy and Procedure (P&P) titled, Links Healthcare Resident Trust Policy.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of six sampled resident ' s (Resident 2) care plans were revised after Resident 2 fell on 2/10/2024, and 7/14/2024. This deficient practice resulted in Resident 2 ' s continued falls and subsequent skin tear and discoloration to the left temporal (the area behind the temples and ears) area of her head following a third fall on 11/15/2024.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of six sampled residents (Resident 1 and Resident 5) were provided incontinence care in a timely manner. This deficient practice resulted in Residents 1 and 5 sitting in a wet and soiled diaper for 55 minutes after they requested assistance and this deficient practice had the potential to cause break down in Resident 1 and 5 ' s skin and cause them to feel uncomfortable, undignified and embarrassed.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of six sampled resident ' s (Resident 2) did not fall an sustain an injury when her care plans were revised after Resident 2 ' s falls on 2/10/2024, and 7/14/2024. This deficient practice resulted in Resident 2 sustaining a skin tear and discoloration to the left temporal (the area behind the temples and ears) area of her head following a third fall on 11/15/2024.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Certified Nursing Assistant (CNA 1) did not turn and reposition a resident (Resident 1) who required a two-person physical assist with bed mobility, by himself, without the assistance of another staff for one of three sampled residents (Resident 1). This deficient practice resulted in Resident 1 ' s left hand scratching his right forearm which resulted in a scratch measuring 0.2 centimeters (cm- unit of measurement) by 2 cm.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) was treated with dignity and respect when the Assistant Director of Nursing (ADON) mentioned to Resident 1 that peace can be found six feet below the ground. This deficient practice resulted Resident 1's feeling sad and depressed.

Inspectors wroteBased on interview and record review, the facility failed to report family member 2's (FM 2) allegation of abuse, involving one of four sampled residents (Resident 1), to the California Department of Public Health (CDPH), State Long Term Care Ombudsman (an agency that assist residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences), and local police within the regulated time frame of two hours. This deficient practice resulted in CDPH's inability to investigate the allegation of abuse timely and had the potential for other allegations of abuse to go unreported.

Inspectors wroteBased on interview, and record review, the facility failed to prevent further potential abuse for one of four sampled residents (Resident 1) after family member 2's (FM 2) reported allegations of abuse by failing to: a. Immediately assess Resident 1's physical and psychosocial status and evaluation of whether the alleged victim felt safe. b. Immediately notify Resident 1's physician. c. Remove access of the Assistant Director of Nursing (ADON) to Resident 1 and other residents after the allegation was reported on 7/19/2024. d. Notify the California Department of Public Health (CDPH), State Long Term Care Ombudsman (an agency that assist residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences), and local police; and e. Provide the five-day conclusion of facility investigation to the CDPH. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to report an injury of unknown origin (the cause of injury was not observed by any person or could not be explained by the resident) to California Department of Public Health (CDPH) for one of three sampled residents (Resident1) when Resident 1 had swelling on the right knee on with a right femur fracture (break in the thigh bone) on 5/29/2024. This failure had the potential to result into a delayed investigation to rule out abuse and neglect.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was prescribed with Percocet (medication used to help relieve moderate to severe pain that contains combination of acetaminophen and oxycodone) were reassessed and monitored for its continued used. This failure had the potential for Resident 1 to receive unnecessary medication and at risk for adverse drug effects (unwanted undesirable effects that are possibly related to a drug) of Percocet.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was transferred from the facility ([DATE]) to a General Acute Care Hospital (GACH) for evaluation and treatment after being found lethargic (a condition marked by drowsiness and an unusual lack of energy and mental alertness) and hypotensive (low blood pressure), was readmitted to the facility after Resident 1 was treated and stabilized at the GACH ([DATE]). This deficient practice resulted in Resident 1 remaining at the GACH for approximately 43-47 days after Resident 1 was deemed appropriate for discharge back to the facility ([DATE] - [DATE]) but was denied readmission by the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure six out of six sampled residents (Resident 38, Resident 78, Resident 237, Resident 81, Resident 80, and Resident 20) had a completed acknowledgement of advance directives and Physician Orders for Life-Sustaining Treatment ([POLST]- a medical order that helps give people with serious illness more control over their care during a medical emergency) in their medical records. These failures had the potential for delay of care and treatment and/ or inadvertently missed health care wishes/ decisions of the residents during emergency, changes in condition and end of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 2 sampled residents (Resident 80) was treated with respect and dignity by failing to provide clean and dry adult incontinence briefs and bed sheets for Resident 80. Resident 80 was observed sitting in saturated adult briefs and wet bed sheets, and urine was leaking from the adult briefs onto the bed sheets. This deficient practice violated the rights of Resident 80's for dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled resident (Resident 20) hand mittens (soft gloves that are designed to restrict the movement of one or both hands, and are used with patients that have removed essential lines or tubes on more than one occasion) restraints (any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body), were assessed, monitored per physician's order dated 2/1/2024 and Resident 20's untitled care plan for restraints initiated on 1/11/2024. These deficient practices had potential to result in skin injury, and compromised circulation of the right hand.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 38) was left unsupervised, while attempting to go to the bathroom. This failure put Resident 38 at an increased risk for fall and injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of four sampled residents (Resident) 12's medication regimen was free from significant medication errors. This deficient practice jeopardized Resident 12's health and safety by the failure to administer the medication via Gastrostomy ([G-tube] a tube inserted through the wall of the abdomen directly into the stomach to deliver nutrition and medication) in accordance with the physician order and/or manufacturer's specification. The failure had the potential for Resident 12 to experience adverse reactions (undesired effect of a drug (medication)) that included but not limited to, severe stomach pains, stomach irritation, or G-tube clogging (an obstruction which makes movement or flow of feeding or medication difficult or impossible).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of four sampled residents (Resident) 12's medication regimen was free from significant medication errors. This deficient practice jeopardized Resident 12's health and safety by the failure to administer the medication via Gastrostomy ([G-tube] a tube inserted through the wall of the abdomen directly into the stomach to deliver nutrition and medication) in accordance with the physician order and/or manufacturer's specification. The failure had the potential for Resident 12 to experience adverse reactions (undesired effect of a drug (medication)) that included but not limited to, severe stomach pains, stomach irritation, or G-tube clogging (an obstruction which makes movement or flow of feeding or medication difficult or impossible).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the proper use of personal protective equipment (PPE- garments, gear or equipment designed to protect from injury or infection) in the kitchen by one of three dietary aides (DA), DA 1. This failure had the potential for DA 1's hair shedding into residents' food he is preparing.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Binding Arbitration Agreement (signed agreement to settle issues with a neutral party instead of going to court) was explained to, and acknowledged by one of the 2 sampled residents (Resident 76). This failure posed the risk for the resident to make uninformed decisions regarding the right to file an appeal if there was any allegations of medical malpractice.

Inspectors wroteBased on observation, interview and record review, the facility failed to protect one of four sampled resident's (Resident 1) right to personal privacy and confidentiality when Certified Nurse Assistant (CNA) 1 photographed Resident 1's Restorative nursing assistant (RNA [provides rehabilitative care to individuals recovering from illnesses or injuries]) notes using her personal cell phone. This deficient practice resulted in the violation of Resident 1's right to privacy and confidentiality and had the potential to negatively affect Resident 1's psychosocial well-being.