Torrance Care Center West, Inc

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff treated residents with dignity and respect by providing attentive, courteous, and respectful interactions during resident communication for one of three sampled residents (Resident 2) when Licensed Vocational Nurse (LVN) 1 engaged in personal activity on a cell phone while interacting with Resident 2. This failure resulted in Resident 2 not being treated with dignity and respect and had the potential for Resident 2 to feel ignored, dismissed, disrespected, unimportant and/or devalued.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff documented personal belongings on the inventory list for one of three sampled residents (Resident 1). This failure has the potential to result in the inability to track Resident 1's personal belongings, verify reports of missing items, and ensure accountability for residents' personal property.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) who had chronic pain (pain that lasts longer than three months) and who had an order for a Transcutaneous Electrical Nerve Stimulation ([TENS] a non-invasive pain relief therapy that uses a compact, battery-powered device to send mild, low-voltage electrical currents through the skin), had the order clarified. This failure resulted in an eight day delay in clarifying information and implementing a physician ordered pain management intervention for Resident 1. This failure had the potential for Resident 1 to experience increased pain or discomfort, decreased mobility, sleep disturbances from uncontrolled pain, increased use of pain medications, and a decline in quality of life and emotional well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) who had chronic pain (pain that lasts longer than three months), that their pain was managed. The facility failed to:1. Monitor Resident 1's pain at least every shift.2. Assess Resident 1's pain before and after administration of pain medications.3. Implement non-pharmacological pain-management interventions (therapies and measures to control pain that do not involve taking medication) to Resident 1.4. Document ongoing pain assessments for a resident with chronic pain. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1) who was diagnosed with Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) did not sustain a second degree burn (damage to the epidermis [top layer of the skin] and part of the dermis [underlying layer] causing painful, red, blistered, and swollen skin) to his right leg. On 12/28/2025, Certified Nursing Assistant (CNA) 1 placed a lunch tray containing a cup of hot water on Resident 1's overbed table (a mobile, height-adjustable table with a narrow, rectangular top designed to slide over a bed or chair) and the cup of hot water fell onto Resident 1's right leg. The facility failed to: 1. [...]

Inspectors wroteBased on interview, and record review, the facility failed to notify the Responsible Party (RP) of one of four sampled residents (Resident 1) when a cup containing hot water was placed on Resident 1's overbed table (a mobile, height-adjustable table with a narrow, rectangular top designed to slide over a bed or chair) and the cup of hot water fell on Resident 1's leg causing a second degree burn (damage to the epidermis [top layer of the skin] and part of the dermis [underlying layer] causing painful, red, blistered, and swollen skin) to Resident 1's right lateral (outside) leg. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 1 accurately documented in the clinical record for one of four sampled residents (Resident 1) when Resident 1 sustained a thermal burn (an injury caused by exposure to heat sources such as hot liquids, steam, fire, or hot objects) to his right lateral (on the outside) leg, but documentation indicated Resident 1's right forearm. This deficient practice resulted in the inaccurate documentation of Resident 1's status and had the potential for confusion and non-continuity of care.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a person-centered care plan that honored resident's food preferences for one of three sampled residents (Resident 1). This deficient practice resulted in Resident 1 expressed dissatisfaction with meals when his food preferences were not consistently followed.

Inspectors wroteBased on interview and record review, the facility failed to ensure food preferences were honored for one of three sampled residents (Resident 1). This deficient practice resulted in Resident 1 not consistently receiving his preferred meals and had the potential to affect Resident 1's nutritional intake and satisfaction with meals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide information on how to file a grievance (an official statement of a complaint over something believed to be wrong or unfair) and its process to one of three sampled residents (Resident 1). This failure resulted in Resident 1 being unable to exercise his or her right to file grievance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and/or implement an individualized person-centered plan of care with measurable objectives and interventions to meet the residents' needs for one of three sampled residents (Resident 1) regarding adjustment of the adult brief (a type of absorbent, tabs-style adult diaper designed for moderate to heavy incontinence) fitting. This failure resulted in Resident 1 feeling embarrassed due to the leakage of urine from the improper adjustment of the adult brief and avoiding activities due to uncomfortable fitting of the adult brief.

Inspectors wroteBased on interview and record review the facility failed to ensure seven of seven sampled residents (Resident 25, Resident 29, Resident 41, Resident 58, Resident 59, Resident 96 and Resident 108) received their mail on Saturdays. This failure resulted in Resident 25, Resident 29, Resident 41, Resident 58, Resident 59, Resident 96 and Resident 108 rights violated to receive mail on Saturdays.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' advance directive forms (a legal document indicating resident preference on end-of-life treatment decisions) were executed by the resident or the resident's legally authorized representative ( is someone authorized to act on behalf of another person in legal matters), and medical records were updated to show documentation that advance directives were discussed and written information was provided to the residents and/or responsible parties for six of 10 residents (Resident 11, 12, 15, 22, 30, and 36). The facility failed to:1. [...]

Inspectors wroteBased on interviews and record review the facility failed to ensure staff were competent with facility policies and procedures by failing to:A. Ensure two of two licensed staff (Registered Nurse Supervisor 1 and Licensed Vocational Nurse 3) were able to verbalize the process for securing emergency medication kits (E-kits). B. Ensure annual performance evaluations (supervisor looks at how well staff are doing their job and gives feedback) were documented and completed for five of five facility staff as required by the facility policy and regulatory standards. This deficient practice had the potential to result in staff competency concerns going unrecognized, unmet training needs, and potential to result in delays during medical emergencies, unauthorized access, and loss of critical medications.

Inspectors wroteBased on interview and record review, the facility failed ensure one of three sampled residents (Resident 168) with Post-Traumatic Stress Disorder (PTSD- a mental health condition that can develop after experiencing or witnessing a traumatic event) was referred to a psychologist (a trained mental health professional who helps people learn healthy ways to handle mental health challenges) per Resident 168 request and physician order. This deficient practice resulted in Resident 168 not receiving the proper assessment, necessary treatment, and resources for his diagnosis of PTSD.

Inspectors wroteBased on observation, interview, and record review , the facility failed to ensure Zyprexa (Olanzapine- medicine that treats mental disorders , including schizophrenia [a mental illness that is characterized by disturbances in thought] and bipolar disorder[sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs])10 milligrams (mgs.- unit of measurement) were not in the same plastic bag mixed with Zyprexa 5 mgs. and labeled for Zyprexa 5 mgs outside the plastic container for one of four sampled residents (Resident 148). This failure had the potential to place Resident 148 at risk for medication error.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure eight of eight residents (Resident 160, Resident 11, Resident 16, Resident 22, Resident 26, Resident 61, Resident 84, and Resident 92) opened medication bottles were labeled with the date opened. This failure had the potential to result in the use of medications beyond their recommended stability period, reducing their efficacy, and compromising resident safety through the administration of expired and contaminated medications.

Inspectors wroteBased on observation interview and record review the facility failed to: 1. Ensure an open date was placed on an open gallon of milk and an open bag of potato chips. 2. Ensure a bin of celery and multiple bags of hotdog buns were not expired.3. Ensure that chicken was defrosted safely, when the chicken was left in a tub of standing water while defrosting in the sink. 4. Ensure the sanitation bucket had sanitizer solution in it. These failures had the potential to expose residents to food-borne illnesses (any illness resulting from ingestion of food contaminated with bacteria, viruses, or parasites) and put residents at risk for cross contamination (unintentional transfer of harmful bacteria from one object to another).

Inspectors wroteBased on interview and record review, the facility failed to ensure the arbitration (a form of dispute resolution where a neutral third party helps resolve a dispute between two or more parties) agreements were accurately completed for three of three sampled residents (Resident 29, 68, and 72). The facility failed to:1. Assess mental capacity (ability to make decisions) and provide information to Residents 29, 68, and 72 before signing the arbitration agreement. 2. Ensure the arbitration agreement forms are fully completed. This failure had the potential to result in Resident's 29, 68, and 72 not fully understanding his/her right to limit the opportunity to initiate judicial proceedings that challenge unfavorable decisions.

Inspectors wroteBased on interview and record review, the facility's Quality Assessment and Assurance Committee (QAA- develop and implement appropriate plans of action to correct identified quality deficiencies) failed to ensure effective oversight of the facility and implementation of the facility's plan of correction (POC) of the deficient practices identified during the previous recertification survey. This failure resulted in the facility having repeat deficiencies in the areas of resident rights, advance directives, Medicare coverage notification, notice of transfer requirements, accuracy of assessments, implementing care plans, social services, pharmacy services, medication storage, and infection control and prevention.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices for two of five sampled residents ( Resident 77 and 98) The facility failed to:1. Ensure Licensed Vocational Nurse (LVN 2) disinfected the medication tray used on Resident 77 before using the tray on another resident during medication pass.2. Ensure soiled gown of Resident 98 was handled and disposed in a sanitary manner.3. Ensure one of one resident (Resident 141) was not allowed to obtain clean linen from the laundry cart. These failures had the potential for cross contamination (transfer of harmful substances, like bacteria from one source to another) and spread of infection to the residents and staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide at least 80 square feet ({sq. ft} unit of measurement) per resident in multiple resident bedrooms for 20 out of 78 resident rooms. This deficient practice has the potential to result in an inadequate provision of safe nursing care and privacy for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light (a vital communication tool, ensuring residents can easily alert nurses or other caregivers when they need help) was in reach and not observed on the floor for one of residents (Resident 90). This deficient practice had the potential to compromise Resident 90's ability to request staff assistance, placed the resident at risk for unmet needs, and deny Resident 90 the right to a dignified environment which could affect their health, safety, and quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess mental capacity(ability to understand information and make decisions) accurately on one of four sampled residents(Resident 22) when the resident was provided an informed consent(voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered)for a psychotropic medication(any drug that affects brain activities associated with mental processes and behavior). This failure had the potential to violate Resident 22's right to be informed.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure reasonable accommodation of needs for one of one resident (Resident 90) when staff did not make the residents' pictogram communication board (involves using simple pictures or symbols to convey important information to residents, especially those with language barriers) accessible. This deficient practice had the potential to impede Resident 90's ability to express her needs, make choices, and participate in care decisions, thereby affecting her dignity and quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 182) was appropriately notified regarding the changes in their Medicare coverage through provision of Notice of Medicare Non-Coverage (NOMNC) ( a form that healthcare providers must give to Medicare beneficiaries to inform them that Medicare is expected to stop covering a specific service or item) form. This deficient practice had the potential to result in the responsible parties not being able to exercise their right to file an appeal.

Inspectors wroteBased on interview and record review, the facility failed to complete the required documentation for a transfer/discharge and assist resident with discharge planning for two of three sampled residents (Resident 51 and Resident 9) by failing to:1. Ensure a written copy of the bed hold notice was created and provided to Resident 51.2. Ensure the Notice of Proposed Transfer and Discharge was provided to the Ombudsman at the time of transfer to the General Acute Care Hospital (GACH) for Resident 51. This deficient practice resulted in the incomplete status of Resident 51's bed hold availability and had the potential to deny Resident 51's protection from being inappropriately discharged .3. Assist Resident 9 to look for placement back into the community.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of two sampled residents (Resident 36 and 182) had:1. Implemented intervention of padded siderails for Resident 36 who had a seizure disorder 2. Developed a care plan for Resident 182 who had a sacrococcyx (tailbone) wound. These failures had the potential to not having appropriate interventions and for injury to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 148) did not receive medication without physician's order. This failure resulted in a medication error and had the potential to place Resident 148 for an adverse reaction(an undesirable or harmful effect from a drug or treatment).

Inspectors wroteBased on observation and interview, the facility failed to ensure two of three sampled residents (Resident 125 and Resident 3) who were dependent on activities of daily living (ADLS- activities such as bathing, dressing, and toileting a person performs daily) received the necessary care and services to maintain good grooming and personal hygiene by failing to:1. Ensure Resident 125 was provided with oral care. 2. Ensure Resident 3's long and dirty fingernails were trimmed. These failures had the potential to result in Resident 125 and Resident 3 feeling neglected and not thoroughly groomed which could lead to skin breakdown, infection and teeth/gum issues.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of one sampled residents ( Resident 152) 152 was provided with reading glasses when his eyeglasses broke. This failure had the potential to negatively affect Resident 152's quality of care and his safety at risk.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure oxygen tubing start date or change date was labeled for one of one resident (Resident 182) who required intermittent oxygen. This failure had the potential for respiratory infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure facility staff provided care to residents with Post-Traumatic Stress Disorder (PTSD- a mental health condition that can develop after experiencing or witnessing a traumatic event) for two of two sampled residents (Resident 168 and 17). The facility failed to:1. Ensure Resident 168 and 17 were assessed, monitored, and provided interventions to help with Resident 168 and Resident 17 triggers. 2. Ensure facility staff who provided care to residents were aware of Resident 168 and Resident 17's diagnoses of PTSD and what triggers to monitor for. 3. Social Services Director (SSD) 1 failed to demonstrate competency on how to assess, document, and identify PTSD and triggers upon admission to the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide medically related social services to meet residents' needs for two of four sampled residents (Resident 3 and Resident 97) needing dental services by failing to:1. Follow up Resident 3's dental recommendation for teeth extraction.2. Follow up Resident 97's dental recommendation for dentures. This failure had the potential to put Resident 3 and Resident 97 at risk for delayed treatment and care which could lead to weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure the facility's activities of daily living tasks (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) binder containing residents' information was left unattended and open at the bedside table near a resident room.2. Ensure telephone orders were transcribed accurately a physician's wound treatment order for one of one resident (Resident 182). These failures had the potential to have unauthorized access to medical records and inaccurate wound treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of three sampled residents (Resident 2 and 3) were free from physical abuse when Resident 1, who had a history of schizophrenia (a mental illness that is characterized by disturbances in thought), anxiety (excessive worry and feelings of fear, dread, and uneasiness), and major depressive disorder ([MDD] a mood disorder that causes a persistent feeling of sadness and loss of interest), suddenly without any provocation, hit Resident 2 on the left side of his face and then proceeded to hit Resident 3 on the right side of his face causing Resident 3 to fall to the floor. Resident 1 was arrested by the local area police. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure licensed vocational nurses (LVNs) were competent during medication administration when, two out of five sampled residents (Resident 1 and Resident 2) received blood pressure lowering medications that did not meet physician ' s parameters (specific instructions). This deficient practice had the potential for Resident 1 and Resident 2 to become hypotensive (low blood pressure, a sudden drop in blood pressure can cause symptoms like dizziness or fainting and can indicate that vital organs aren't getting enough blood flow.)

Inspectors wroteBased on interview and record review, the facility failed to ensure two out of five sampled residents (Resident 1 and Resident 2) was free from a significant medication error by failing to follow the physician ' s ordered parameters (specific instructions) when administering blood pressure lowering medications. This deficient practice had the potential for Resident 1 and Resident 2 to become hypotensive (low blood pressure, a sudden drop in blood pressure can cause symptoms like dizziness or fainting and can indicate that vital organs aren't getting enough blood flow.).

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident who was assessed as a high risk for falls and required assistance from staff during transfers, was provided with safe and appropriate transfer assistance to avoid a fall for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure Certified Nurse Assistant (CNA) 1 utilized a gait belt ([transfer belt] a device placed on a resident who has mobility issues to aid in safe movement for the resident) upon transferring Resident 1. 2. Ensure Resident 1 ' s Care Plan included specific interventions indicating the requirement for two-person assistance when transferring Resident 1, in compliance with the facility ' s procedure Transfer from a Bed to a Wheelchair. [...]

Inspectors wroteDuring an interview and record review the facility failed to ensure grievance was investigated and resolved promptly for one of one sampled resident (Resident 2). This deficient practice had the potential for Resident 1 concerns unresolved.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement an individualized care plan with measurable objectives, timeframes, and interventions for one of three sampled residents This failure had the potential to place Resident 4 at increased risk for further falls and for injury from a fall. Findings During a review of the admission Record, the admission Record indicated Resident 4 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including epilepsy (seizures), extrapyramidal and movement disorder (involuntary movements that you cannot control), and schizoaffective disorder (a mental illness that can affect your thoughts, mood, and behavior). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 5 of 5 sampled residents (Residents 6, 117, 122, 141, and 157) who were smokers, had an environment free of accident hazards (risk), by failing to: 1. Implement guidance from the Resident Smoking Assessment Form which indicated all residents' smoking materials and paraphernalia must be safely stored by facility staff. 2. Ensure Residents 6, 141, 122, 157, and 117 were not in possession of smoking materials (cigarettes and lighters). 3. Provide supervision while smoking for Residents 141, 157, and 117 identified as unsafe smokers. 4. Follow its policy and procedure (P&P) titled, Accidents and Supervision, which indicated staff will observe and identify potential hazards in the environment. 5. [...]

Inspectors wroteBased on interview and record review, the facility failed to employ a Social Worker on a full-time basis that met the qualifications specified in the regulation. This deficient practice had the potential for 175 out of 175 residents residing in the facility to not be assisted and receive medically related necessary care and behavioral health services to attain their highest practicable well-being.

Inspectors wroteBased on interview and record review, the facility's Quality Assessment and Assurance ([QAA] develop and implement appropriate plans of action to correct identified qualify deficiencies) and Quality Assurance Performance Improvement ([QAPI] takes a systematic, interdisciplinary, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes while involving residents and families, and all nursing home caregivers in practical and creative problem solving) committee failed to: 1. Employ a qualified social worker on a full-time basis that meet the qualifications specified in the regulation. This deficient practice had the potential for 175 out of 175 residents residing in the facility to not be assisted and receive medically related necessary care and behavioral health services to attain their highest practicable well-being. 2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one out of six Residents (Resident 12) was treated with dignity by having Resident 12 walk around the facility without proper shoes. This deficient practice of Resident 12 not wearing shoes had the potential for Resident 12 to experience loss of dignity and self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to complete the Physician Orders for Life-Sustaining Treatment ([POLST] patients treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency) form was completed for one out six residents (Resident 125) This deficient practice of not having the POLST completed had the potential for Resident 125's wishes not to be carried out in the time of distress.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled resident (Resident 237) was appropriately notified regarding the changes in their Medicare coverage through provision of Notice of Medicare Non-Coverage (NOMNC) form. This deficient practice had the potential to result in the responsible parties not being able to exercise their right to file an appeal.

Inspectors wroteBased on interview and record review, the facility failed to implement behavioral modification and dementia care techniques prior to notifying the physician (MD) for one of three sampled residents (Resident 186). This failure had the potential to result in Resident 186's being inappropriately assessed and transferred to the GACH.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Notice of Proposed Transfer/Discharge form was completed and sent to the Office of the State Long-Term Ombudsman (public advocate for residents in long-term care facilities) for one of one sampled residents (Resident 186) who was transferred to the general acute care hospital (GACH). This failure had the potential to result in Resident 186 being denied additional protection from being inappropriately discharged and access to an advocate who could inform them of their options and rights.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three closed record sampled residents' (Resident 186) discharge status on the Minimum Data Set ([MDS], a resident care and screening assessment tool) was encoded correctly. This deficient practice resulted in incorrect data transmitted to Centers for Medicare and Medicaid Services (CMS) and had the potential to affect continuity of care.

Inspectors wroteBased on interview and record review, the facility failed to ensure one out six sampled residents (Resident 126) had a complete dental assessment upon admission. This deficient practice of not completing the dental assessment had the potential of Resident 126 to not receive good and services.

Inspectors wroteBased on interview and record review, the facility failed to complete and transmit one of three residents (Resident 132) Preadmission Screening and Resident Review ([PASARR] an evaluation that determines whether an individual has mental illness and selects the appropriate services for the individual) Level II. This failure had the potential to result in Resident 132 not receiving specialized services for mental illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement an individualized care plan with measurable objectives, timeframes, and interventions for three out of 36 sampled residents (Resident 61, 6 and 139). a. For Resident 61 with bilateral bed rails (a rail attached to the side of the bed to prevent someone from falling out of the bed or to help in movement). b. For Resident 6 who was a smoker. c. For Resident 139 who refused dental services. These failures had the potential to negatively affect the delivery of necessary care and services for Resident 61,6 and 139.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one out of six Residents (Resident 12) had a revised care plan for not wearing shoes to prevent falls. This deficient practice of not revising a care plan for not wearing shoes with Resident 12 place the Resident 12 at risk falls.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident urinary output (amount of urine and fluid a person excrete) was monitored for one of two sampled residents (Resident 31) who had an indwelling foley catheter (a flexible plastic tube inserted into the bladder to provide continuous urinary drainage) as indicated in the plan of care and physician's order. This deficient practice had the potential to result in urinary retention (inability to urinate) and delayed identification of urinary tract infection ([UTI] an infection that can occur in any part of the urinary system, kidneys, bladder, ureter, or urethra).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate use of bed rails (are adjustable metal or rigid plastic bars that attach to the bed) for one of 36 sampled residents (Resident 61), as indicated in the facility's policy and procedure by failing to: 1. Complete a siderail assessment per facility's policy and procedure. 2. Ensure Resident 61 had a physician order for the use of bed rails. 3. Ensure Resident 61 had a signed consent for the use of bilateral siderails. 4. Implement a care plan for the use of bedrails. These deficient practices had the potential to physical harm from possible entrapment (when a person is trapped by the bed rail in a position they cannot move from) from the use of bed rails for Resident 61.

Inspectors wroteBased on interview and record, the facility failed to ensure a follow up appointment for a cataract (a medical condition in which the lens of the eye becomes cloudy) evaluation/referral was completed for one of 6 sampled residents (Resident 106). This deficient practice had the potential to result in the delay of necessary care and services for Resident 106.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a Controlled Drug Record form (a log containing the date, time, quantity, and nurse's signature each time a dose is administered) was completed accurately. This deficient practice increased the risk of loss or diversion of controlled medications (a drug or other substances that is tightly controlled by the government because it may me abused or cause addiction and may cause significant risk to patient safety).

Inspectors wroteBased on observation, interview, and record review, the facility failed to remove one packet of expired norethindrone (medication for birth control) for Resident 168 from the medication cart. This deficient practice had the potential to result in the use of ineffective medication for Resident 168.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure dental services were obtained for one of 6 sample residents (Resident 169). This deficient practice had the potential to result in Resident 169's inability to chew foods and potentially result in weight loss, lack of energy and loss of muscle mass.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and observe infection control practices by failing to: a. Practice hand hygiene. b. Disinfect residents smoking aprons after each use. These deficient practices had the potential to result in cross contamination (physical movement or transfer of harmful bacteria from one person, object, or place to another) and place residents at risk for the spread of infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide at least 80 square feet ([sq. ft.] unit of measurement) per resident in multiple resident bedrooms for 20 out of 78 resident rooms. This deficient practice had the potential to result in an inadequate provision of safe nursing care, and privacy for the residents.

Inspectors wroteBased on interview and record review, the facility failed to report one of four sampled resident ' s (Resident 1) allegation of sexual abuse to the California Department of Health (CDPH) and 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) within the regulated time frame of two hours. This deficient practice resulted in CDPH's inability to investigation the allegation of sexual 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 investigate an allegation of abuse and provide the five-day conclusion to their investigation to the California Department of Health (CDPH) after one of four sampled resident's (Resident 1) made an allegation of sexual abuse. This deficient practice resulted in the inability of the facility to determine if Resident 1's allegation of sexual abuse was true, had the potential for other allegations of abuse to not be investigated and failure to protect residents from abuse.

Inspectors wroteBased on interview and record review, the facility's Quality Assessment and Assurance (QAA) committee failed to identify quality deficiencies with allegations of abuse and care plans. This deficient practice resulted in the facility not developing and implementing appropriate plans of action to correct identified quality deficiencies, measuring its success, and tracking performance to ensure improvements are realized and sustained.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nursing staff complied with infection prevention and control protocols to provide a safe, sanitary environment to help prevent the development and transmissions of communicable diseases and infections. This deficient practice had the potential to result in the transmission of communicable diseases and infections among residents and staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure five out of five (5) sampled residents (Residents 86, 158, 149, 470, and 147) received treatment and care in accordance with professional standards of practice to meet the resident's physical, mental, and psychological needs as evidenced by: 1. For Resident 86, there was no care plan to reflect the resident's behaviors of being aggressive during feeding assistance, nor did resident receive the correct diet type as ordered by the physician; 2. For Resident 158, who reported abdominal pain, there was no assessment, monitoring, care planning, or notification of the physician or resident's family in a timely manner; 3. For Resident 149, there was no assessment or monitoring of a change of condition for which the resident was transferred to a local hospital for generalized weakness and lightheadedness; 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure licensed nursing staff completed pre and post hemodialysis (treatment to filter wastes, salts, and fluid from blood for those with kidney failure) assessments in accordance with standards of practice for two out of five (5) sampled residents (Residents 122 & 123). In addition, the facility failed to ensure licensed nursing staff accurately assessed the hemodialysis access site for Resident 123. This deficient practice had the potential to result in delayed detection of complications of the dialysis access site.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to: 1. Ensure that the change of shift narcotics reconciliation record, for one (1) out of two (2) observed medication carts, out of four (4) total medication carts at the facility, was not missing one (1) licensed nurse's signature in the designated signature box over a one (1) month period. This deficient practice had the potential for loss of accountability, which affected the controls against drug loss, diversion, or theft. 2. Ensure that a change of shift narcotics reconciliation record, for one (1) out of two (2) observed medication carts, out of four (4) total medication carts at the facility, did not have one (1) pre-filled licensed nurse signature in a designated signature box for a future narcotics reconciliation verification to be conducted by two (2) licensed nurses. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to: 1. Ensure that one (1) bottle of an over-the-counter medication was not expired, located in one (1) out of three (3) observed medication storage rooms, out of five (5) total medication storage rooms at the facility. This deficient practice had the potential for harm to residents due to the potential loss of strength of the medication, and the potential for the residents to receive ineffective medication dosages due to expired medication. 2. Ensure that the refrigerator temperature was within the temperature range specified for refrigerated medications, in one (1) out of three (3) observed medication storage rooms, out of five (5) total medication storage rooms at the facility. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure two of eight sampled residents (Residents 29 and 128), Minimum Data Set (a documentation of the resident's clinical assessment [MDS]) was revised after a significant change in condition. This deficient practice had the potential to result in creating an inaccurate picture of the residents' health status.

Inspectors wroteBased on interview and record review the facility failed to submit and transmit the Minimum Data Set (comprehensive screening tool [MDS]) Discharge Assessment to the Center for Medicare and Medicaid Services (CMS) for one of two Residents (Resident 2). This deficient practice had the potential to negatively impact the quality monitoring and discharge tracking for Resident 2

Inspectors wroteBased on interview, and record review, the facility failed to ensure two of eight residents (Residents 29 and 128) had an accurate Activity of Daily Living (daily self-care activities [ADL]) assessment. This failure placed resident 29 and 128 at risk for further decline in their functional mobility and prevented proper care planning.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a person-centered care plan addressing joint mobility for one of eight sampled residents (Residents 79). This failure had the potential to delay provision of necessary care and services.

Inspectors wroteBased on observation, interview and record review, the facility failed to accommodate and meet the needs of the resident's food preference for a kosher diet and meeting the individual resident's religious, cultural and ethnic preferences for 1 out of 8 Residents, (Resident 119). This deficient practice resulted in the resident's food preferences not being honored and had the potential for malnourishment and weight loss.

Inspectors wroteBased on observation and interview, the facility failed to maintain equipment in the kitchen when the following was observed during the initial kitchen tour in Building B: 1. Dishwasher temperature was observed at 110 degrees 2. Four concentrated juice boxes were observed undated. These failures have the potential to cause food borne illness and spread infection to all residents. 1. During a concurrent observation, interview and record review during the initial kitchen tour in building B on 11/16/21 at 8:50 a.m. with Assistant Dietary Supervisor (ADS), it was observed that during a cycle of running the dishwasher, the temperature only reached 110 degrees. The cycle was performed twice, and the temperature was still at 110 degrees. The ADS also said that the temperature should be above 120 degrees. [...]