Valley View Post Acute

Inspectors wroteBased on interview and record review, the facility failed to ensure two of two sampled residents' (Residents 41 and 86's) Minimum Data Set (MDS, a resident assessment tool) reflected an accurate assessment, by failing to: a. Ensure Resident 86's fall on 5/28/2026 was coded accurately in MDS assessment dated [DATE]. b. Ensure Resident 41's number of days that insulin (a hormone that helps a resident's body use sugar for energy) injections were received since admission was coded accurately in the initial MDS assessment dated [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement specific, comprehensive, and individualized person-centered care plans (CP) to meet the residents' needs for three of four sampled residents (Residents 10, 75, and 86) by failing to:a. Develop an individualized CP to address the automatic implantable cardioverter-defibrillator (AICD, a small, battery-powered medical device implanted in the chest that continuously monitored the resident's heart rate) for Resident 10. c. Develop an individualized CP to address smoking safety for Resident 75. d. Develop an individualized CP to address the actual fall on 5/28/2026 for Resident 86. These deficient practices had the potential for Residents 10, 75 and 86 not to received appropriate nursing care based on Residents 10, 75 and 86's needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe environment for one of one sampled resident (Resident 75) and one of one facility hallway, when:a. Resident 75 had a pack of cigarettes (tobacco wrapped in paper) on the wheelchair at bedside on 6/16/2026.b. The facility did not ensure the floor in the hallway and residents' rooms were free from water after showering the residents. These deficient practices had the potential to increase the risk of accidental fire, injury and harm for the residents, staff and visitors in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its policy and procedures (P&P) titled, Respiratory Therapy-Prevention of Infection, dated March 2024, for two of two sampled residents (Resident 11 and Resident 63) by failing to ensure Resident 11's and Resident 63's nasal cannula (NC, a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) tubing was labeled when changed. This failure had the potential to result in contamination of Resident 11's and Resident 63's care equipment, placing the residents at risk of infection.a. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to discard seven mustard bottles with a use by date of 5/27/2026 from the dry food storage room in one of one facility kitchen (Kitchen 1). This deficient practice had the potential to result in food-borne illnesses (illness caused by ingesting contaminated food or beverages) for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control in accordance with its policy in one of one facility kitchen (Kitchen 1), when the following items intended for staff use were kept inside the kitchen's dry food storage room: a. An unlabeled resealable bag (one gallon size) containing plastic spoons, sugar packets, coffee creamer packets, and tea bags. b. An unlabeled resealable bag (one quart size) containing plastic cup lids. c. A wooden caddy organizer (wooden box divided into smaller sections) containing individual packets of sugar, coffee creamer, hot sauce, and ketchup. These deficient practices had the potential to spread infection among residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have an effective pest control program for one of one sampled resident (Resident 15). This failure resulted in gnats (tiny, two-winged flying insects) in Resident 15's room and in patient care areas being a nuisance and had the potential to lead to food contamination and infection risks. During a review of Resident 15's admission Record (AR), the AR indicated the facility admitted Resident 15 on 12/31/2025 with diagnoses that included Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) and low back pain. During a review of Resident 15's History & Physical (H&P), dated 3/6/2026, the H&P indicated the resident had the capacity to understand and make decisions. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep the call light (an alerting device for nursing staff to assist a resident when in need) within reach for one of two sampled residents (Resident 59). This deficient practice had the potential to prevent Resident 59 from being unable to call for nursing assistance when needed.

Inspectors wroteBased on interview and record review, the facility failed to ensure the initial Minimum Data Set (MDS - a resident assessment tool) assessment for one of two sampled residents (Residents 41) was completed within 14 days after Resident 41's admission on [DATE], in accordance with statutory regulations. This deficient practice resulted in the late completion of Resident 41's initial MDS assessment and the potential to result in delayed care planning.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled resident (Resident 50), had a revised care plan for a hemodialysis (HD, a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) schedule and fluid restriction. This failure placed Resident 50 at risk for improper HD care, fluid overload, and other HD related complications. During a review of Resident 50's admission Record (AR), the AR indicated Resident 50 was readmitted to the facility on [DATE] with diagnoses that included End Stage Renal Disease (ESRD-irreversible kidney failure), and dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 82) had both Pressure Relief Ankle-Foot Orthosis (PRAFO, adjustable, rigid brace that prevents contracture [a stiffening/shortening at any joint, that reduces the joint's range of motion] and prevents pressure ulcer [localized damage to the skin and/or underlying tissue usually over a bony prominence] on the heels) braces on as ordered by the physician. This failure had the potential for Resident 82 developing worsening muscle weakness, worsening foot drop (inability or difficulty to lift the front part of the foot, causing toes to drag along the ground when walking) and pressure ulcers on the heels. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its Policy and Procedure (P&P) titled, Foods Brought by Family/Visitors, by failing to label and properly store the outside food for Resident 72 This deficient practice had the potential to result in food-borne illnesses (food poisoning) for Resident 72 and could lead to serious medical complications and hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to report an injury of unknown source to the California Department of Public Health (CDPH) for one of ten sampled residents (Resident 1). This failure resulted in the delay of notification to CDPH and had the potential for Resident 1 to be subjected to abuse while at the facility. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included cerebral infarction (damage to brain tissue caused by loss of blood flow to a part of the brain) and left side hemiparesis (weakness in the arm, leg, and face on one side of the body). [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a care plan (summary of a person's health condition, care needs, treatments, goals of treatment, and specific interventions for each identified condition or care need) for one of ten sampled residents (Resident 1) when: 1. There was no care plan regarding Resident 1's fall on 5/3/2026 found in Resident 1's medical record. 2. There was no care plan regarding Resident 1's behavior of getting Resident 1's arm stuck in the bed rail found in the Resident 1's medical record. These failures had the potential for Resident 1 not receiving appropriate care and services. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure one of ten sampled residents (Resident 1) received care and services to prevent accidents when: 1. A Fall Risk Assessment (evaluation conducted to predict the likelihood that a resident will fall) was not completed after Resident 1 had a fall on 5/3/2026. 2. Resident 1 was not assessed by Rehabilitation Department (unit dedicated to help individuals restore physical, mental, cognitive, or vocational abilities lost due to disease, injury, or surgery) after Resident 1's fall on 5/3/2026. 3. Change of Condition (COC, a sudden clinically important deviation in the resident's health or functioning that requires further assessments and interventions) Evaluation was completed when Resident 1's arm got stuck in bed rail. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was permitted for readmission to the first available bed in a semi-private room after Resident 1 was transferred to General Acute Care Hospital (GACH) 1 on [DATE] and transferred to Long-Term Acute Care Hospital (LTACH) 1 on [DATE], in accordance with the facility's policy and procedure (P&P) titled, Bed-Holds and Returns, when the facility failed to permit the resident in a manageable condition return to the facility on [DATE]. This deficient practice resulted in Resident 1 remaining in Long-Term Acute Care Hospital (LTACH) 1 on [DATE] following an inquiry from LTACH 1 for Resident 1 to be transferred back to the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light was within reach for two of two sampled residents (Resident 241 and Resident 28) in accordance with the facility's policy titled Answering the Call Light. This failure had the potential to result in Resident 241 and Resident 28 not receiving care or receiving delayed services to meet the residents' needs and could result in a fall or injury.

Inspectors wroteBased on interview and record review, the facility failed to accurately encode the hearing capability and the discharge status on the Minimum Data Set (MDS- a resident assessment and care screening tool), for two of two sampled residents (Residents 51 and 88). a. Resident 51's hearing need was not addressed resulting in a delay in evaluation for hearing aids. b. Resident 88 discharge status was incorrectly coded as discharged to a General Acute Care hospital on 2/15/25. Resident 88 was discharged to Skilled Nursing Facility (SNF). These failures resulted in inaccurate assessment and had the potential to negatively affect the residents' quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement its policy and procedure on Nutritional Management and Care Plans, Comprehensive Person - Centered for two of two sampled residents (Resident 84 and Resident 15) by failing to: a. Ensure Resident 84's fluid intake was accurately monitored as ordered by the primary doctor and an individualized/person-centered care plan was developed and implemented. b. Ensure Resident 15 had weekly weights recorded after a 15-pound (lb.) weight gain. These failures had the potential to result in complications related to electrolyte imbalance for Residents 84 and 15.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary care and services for gastrostomy tube (GT, a tube inserted through the abdomen that delivers nutrition directly to the stomach) site as ordered by the physician and as indicated in the plan of care for two of two sampled residents (Residents 42 and 7). These failures had the potential for complications related to tube feedings for Residents 42 and 7.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Residents 58 and 241) who were receiving oxygen therapy was provided respiratory care and resident safety in accordance with the facility's policy and procedure titled Respiratory Therapy-Prevention of Infection, Oxygen Administration, and professional standard of practice. This deficient practice had the potential to increase the risk of the spread of infection and a risk for shortness of breath and/or hypoxia (low levels of oxygen in the body tissues) which could lead to serious respiratory complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper food storage and sanitation standards by failing to: a. Ensure food was stored in a sanitary manner when one bag of tortillas was left open in the dry storage area. b. Ensure the kitchen ice machine was without pink and black substances in the interior component of the ice machine. These failures had the potential to result in foodborne illness (illness caused by consuming contaminated food or beverages).

Inspectors wroteBased on interview and record review, the facility failed to implement its Policy and Procedure (P&P) on antibiotic stewardship (a coordinated program that aims to improve the appropriate use of antibiotics to enhance patient outcomes, prevent antimicrobial, and decrease the spread of drug-resistant infections) for three of six sampled residents (Residents 78, 190, and 240). These failures had the potential to result in increased antibiotic resistance (ability of bacteria to withstand the effects of antibiotics, making standard treatments ineffective) and providing antibiotics without relevant justification.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Physician Orders for Life-Sustaining Treatment (POLST, a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of-life) and Advance Directive (AD, a legal document indicating resident preference on end-of-life treatment decisions) Acknowledgement Form were completed upon admission for one of one sampled resident (Resident 35) in accordance with the facility's Policy and Procedure (P&P) on AD. This failure had the potential for the facility staff to provide medical treatment and services against the will of Resident 35.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the resident with a communication device with the language that the resident understood for one of one sampled resident (Resident 70). This failure had the potential to affect Resident 70's communication with staff and delay the provision of care, treatment, and services the resident needed.

Inspectors wroteBased on observation, interview, and record review the facility failed to assess the resident's skin condition and report the skin condition to the physician for one of one sampled resident (Resident 49). This failure resulted in the resident experiencing unrelieved itchiness in her vaginal and buttock areas.

Inspectors wroteBased on interview and record review, the facility failed to provide care and services to meet the resident's need for one of one sampled resident (Resident 51) by failing to ensure Resident 51 who had difficulty hearing was scheduled for an audiology consult and/or hearing aids. This failure resulted in the resident's inability to hear adequately, requiring the resident to be spoken to loudly, and for the resident to lip read during conversation.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident was repositioned every two hours to prevent further skin breakdown (prolonged pressure on the skin causing tissue damage and potentially open sores) for one of one sampled resident (Resident 44). This failure placed the resident at risk of further deterioration of a sacro-coccyx (lowest sections of the spine) Stage 4 pressure ulcer (ulcers that extend deep into the tissue reaching the bones).

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident had an environment free from accident hazards (risks) for one of four sampled residents (Resident 7) by failing to: 1. Ensure Resident 7 was provided with adequate supervision during the performance of activity of daily living (ADL, activities such as bathing, dressing, and toileting a person performs daily). 2. Ensure licensed staff developed an individualized person-centered care plan for Resident 7 who was assessed as high-risk for falls. These failures placed Resident 7 at risk of recurrent falls and injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary care and services for a resident with Foley Catheter (FC, a medical device that helps drain urine from the bladder) in accordance with the facility's Policy and Procedure (P&P) on catheter care for one of two sampled residents (Resident 69). This failure had the potential to result in catheter-related complications for Resident 69.

Inspectors wroteBased on observation, interview and record review, the facility failed to attempt to use appropriate alternative interventions before installation of bilateral (both sides) siderails (also known as bedrails, vertical bars or structures attached to the sides of a bed) for one of one sampled resident (Resident 43). This failure placed Resident 43 at risk for entrapment (when a resident can get caught by the head, neck, chest, or other body parts in the tight spaces around the bedrail) and physical injuries.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure its binding arbitration agreements included selection of a venue convenient to both the facility and resident/resident responsible party for one of three sampled residents (Residents 60). This deficient practice placed Resident 60 at risk for an unjust arbitration and delayed arbitration hearing in an event of an arbitration dispute.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure signage was posted and a personal protective equipment (PPE equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) cart was provided to one of six sampled residents (Resident 240) with MRSA of the wound placed on Enhanced Standard Precaution (ESP, an approach for the use of PPE to reduce transmission of multidrug-resistant organisms [MDRO] between residents in skilled nursing facilities) in accordance with the facility's policy and procedure title Enhanced Barrier Precautions. This deficient practice had the potential to transmit infectious microorganisms and increase the risk of infection for the residents and staff which could result in a widespread infection in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a minimum of 80 square feet (sq. ft., unit of measurement) per resident area for sixteen (16) out of thirty-two (32) resident rooms (Rooms 2, 3, 4, 5, 6, 8, 10, 11, 22 24, 28, 29, 30, 31, 32, and 33) This deficient practice had the potential to impact the ability to provide safe nursing care and privacy to the residents.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of resident-to-resident abuse for two of four sampled residents (Residents 3 and 4) to the State Licensing and Certification Agency (responsible for the licensing or certification of health care facilities), the Ombudsman and to the local law enforcement within two hours, in accordance with the facility's Policy and Procedure (P&P) on Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating. This deficient practice had the potential for delayed investigation that would compromise Residents 3 and 4's safety with potential for further abuse.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure two of three sampled milk drinks were prepared at 41 degrees Fahrenheit (F, a unit used to measure temperature) or lower as indicated in the facility's Policy and Procedure (P&P) titled, Food Receiving and Storage. This deficient practice had the potential to cause foodborne illness (illness from eating contaminated food) to already compromised residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide one to one activity to two of two sampled residents (Residents 33 and 34) for five consecutive days (May 20, 2024 to May 24, 2024) in accordance with the residents' plan of care. These deficient practices had the potential to result to boredom or loneliness which could affect the physical, emotional, and psychosocial well-being of Residents 33 and 34.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow physician's order to administer oxygen continuously to two of two sampled residents (Residents 15 and 58). These failures had the potential to result in the resident not receiving enough oxygen leading to a decline of health condition for Residents 15 and 58.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post accurate staffing information of actual hours worked by the licensed and unlicensed nursing staff directly responsible for resident care per shift daily for two of two days inspected (5/21/2024 and 5/22/2024). The staffing information included the actual worked hours of the Minimum Data Set (MDS) nurse that was not directly responsible for resident care. The staffing information did not indicate the name of the facility. This failure had the potential to affect resident care from inadequate staffing.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure quaternary ammonium (chemical used as disinfectant) sanitizer solution used for cleaning the food preparation area and dishwasher chlorine had the required concentration for sanitizing for one of one facility kitchen. 1. The sanitizing solution the facility used was zero (0) parts per million (ppm, unit of measurement used to describe very small concentrations of a substance in a larger solution) and the recommended concentration for cleaning solution was 100 ppm. 2. The Low-Temperature Dishwashing Machine (wash and rinse cycles that run between 120- and 150-degrees Fahrenheit that require chemical sanitizers) chlorine level was 10 ppm and the recommended Low-Temperature Dishwashing Machine chlorine was 50-100 ppm. [...]

Inspectors wroteb. During a review of Resident 41's AR, the AR indicated the facility admitted the resident on 4/14/2020 and readmitted on [DATE] with diagnoses that included End Stage Renal Disease (ESRD - person's kidneys cease functioning on a permanent basis) and dependence on renal dialysis (treatment for kidney failure that removes toxins, waste products and excess fluids by filtering the blood). During a review of Resident 41's MDS dated [DATE], the MDS indicated the resident had intact cognition. The MDS indicated Resident 41 required maximal assistance (helper lifts or holds trunk or limbs and provides more than half the effort) for all activities of daily living except eating where the resident required set up. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the physician of a change in skin condition and follow its policies and procedures titled Skin Conditions for one of one sampled resident (Resident 18). This deficient practice had the potential for the facility to not implement the necessary management and worsen Resident 18's skin condition.

Inspectors wroteBased on interview and record review, the facility failed to provide notification to Ombudsman (an individual who serves as an advocate for patients) of the facility-initiated discharge for one of three sampled residents (Resident 65). This failure had the potential to result in resident being inappropriately discharged .

Inspectors wroteBased on interview and record review, that facility failed to turn and reposition one of one sampled resident (Resident 58) every two hours on 5/17/2024, 5/20/2024, and 5/22/2024. This failure had the potential for Resident 58 to sustain skin breakdown and possibly, develop a pressure injury (caused when an area of skin is placed under pressure and breaks down the skin and underlying tissue).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide wound care treatment daily as ordered for one of one sampled resident (Resident 289). Wound care treatment was ordered for Resident 289 on 5/16/2024 and was started on 5/18/2024. This failure had the potential for Resident 289's left heel unstageable pressure ulcer (type of bed sore that occurs due to prolonged pressure on a specific area on the skin and is covered by eschar [dry, black, hard dead tissue]) to worsen.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide appropriate care to prevent urinary tract infection ([UTI]an infection in any part of the urinary system [kidneys, bladder, ureters, and urethra]) for one of two sampled residents (Resident 1) on indwelling catheter (collects urine by attaching to a drainage bag) by failing to ensure staff monitor Resident 1's urine output and notify the physician promptly for signs and symptoms of UTI. This deficient practice placed Resident 1 at risk for infection from delayed treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to reassess pain for one of one resident (Resident 40) after pain medication was administered. This deficient practice resulted in Resident 40 to continue to experience pain.

Inspectors wroteBased on observation, interview and record review, the facility failed to attempt the use of appropriate alternatives to bed rails before its installation for one of one sampled resident (Resident 59). This deficient practice placed Resident 59 at risk for entrapment and injury from the use of bed rails.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 59) on psychotropic drugs (any drug that affects brain activities associated with mood, emotions, and behavior) was free from unnecessary medications by failing to ensure staff attempted a Gradual Dose Reduction ([GDR] the stepwise tapering of a dose to determine if symptoms, condition, or risks can be managed by a lower dose or if the dose or medication can be discontinued) of Resident 59 for the use of Quetiapine Fumarate ([antipsychotic drug] a drug use to treat symptoms of psychosis or disconnection from reality) 25 milligram ([mg] unit of measurement) since ordered on 2/29/2024. This deficient practice placed Resident 59 at risk for adverse drug reaction (a harmful and unintended response to a medicine).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 16 of 32 resident rooms (Rooms 2, 3, 4, 5,6, 8, 10, 11, 22, 24, 28, 29, 30, 31, 32 and 33) met the requirement of 80 square feet (sq. ft.) per resident in multiple resident bedrooms. This deficient practice had the potential to affect the care provided to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), was provided with a comfortable environment by failing to: Maintain hot water temperature of the water faucet in the restroom sink of Resident 1's room (Room A) in accordance with the facility's policies and procedures (P&P) titled, Residential Care Facilities for the Elderly and Accommodation of Needs. This deficient practice resulted in Resident 1 not having hot water to use in the restroom and had the potential for Resident 1 to feel uncomfortable during routine personal care.

Inspectors wroteBased on interview and record review, the facility failed to ensure a safe and orderly discharge from the facility for one of two sampled residents (Resident 2) by failing to: 1. Ensure the Social Services Director (SSD) and/or Quality Assurance Nurse (QAN) checked and confirmed a safe and appropriate discharge location for Resident 2, who had a documented history of homelessness (the state of having no home). 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a post-discharge (after discharge) plan of care in accordance with the facility's policy and procedure (P&P) titled, Discharge Summary and Plan, for one of two sampled residents (Resident 2). This deficient practice had the potential for Resident 2 not to receive the necessary information for provision of care after discharge to ensure a safe transition to Resident 2's new living environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents ' room (Resident 1 ' s room) met the requirement of 80 square feet (sq. ft.) per resident in room [ROOM NUMBER]. room [ROOM NUMBER] was previously denied by Center for Medicare and Medicaid Services (CMS). The facility failed to comply after the request for the room waiver was denied by the CMS. This deficient practice had the potential to result in inadequate nursing care to the resident.

Inspectors wroteBased on interview and record review, the facility failed to provide appropriate pain management for one of six sampled residents (Resident 4) by failing to: 1. Ensure Licensed Vocational Nurses (LVN) 3 and 4 called Medical Doctor (MD) 1 to obtain a new order when Resident 4 experienced lower back pain (pain in lower portion of the back) ranging from eight (8) to 10 out of 10 based on a numerical rating scale (NRS, requiring the resident to rate their pain on a defined scale, zero (0) to 10, 0 being no pain, one (1) to three (3) being mild pain, four (4) to six (6) being moderate pain, seven (7) to nine (9) being severe pain and 10 being the worst pain imaginable/very severe pain) on 10/18/2023, at 4 am. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to supervise medical care by a licensed physician according to the facility ' s policy and procedure (PP) titled, Physician Services, for one of six sampled residents (Resident 4) by failing to: 1. Ensure Medical Doctor (MD) 1 provided treatment to authorize Norco (Hydrocodone-acetaminophen, used to treat moderate pain) 5-325 milligram (mg, unit of measurement) to be delivered by the pharmacy per Resident 4 ' s Order Listing Report (OLR) when contacted by the facility staff. 2. Ensure the Medical Director (MDD) was reachable by phone to provide treatment for Resident 4's pain when MD 1 was not reachable by phone by facility staff. As a result of these failures, Resident 4 endured 12 hours of severe pain before being transported to General Acute Care Hospital (GACH) 1 for pain relief. Cross Reference:

Inspectors wroteBased on interview and record review, the facility failed to communicate medical care problems to the medical staff in a timely, efficient, and effective manner according to the facility's policy and procedure (PP) titled, Guidelines for Notifying Physicians of Clinical Problems, by failing to for one of six sampled residents (Resident 4) by failing to: Ensure Medical Doctor (MD) 1 was notified when Resident 4 experienced lower back pain (pain in lower portion of the back) ranging from eight (8) to 10 out of 10 based on a numerical rating scale (NRS, requiring the resident to rate their pain on a defined scale, zero (0) to 10, 0 being no pain, one (1) to three (3) being mild pain, four (4) to six (6) being moderate pain, seven (7) to nine (9) being severe pain and 10 being the worst pain imaginable/very severe pain) on 10/18/2023, at 4 am. [...]

Inspectors wroteBased on observation and interview, the facility failed to treat two of three sampled residents (Resident 1 and 2) with kindness, respect, and dignity based on the facility ' s policy and procedure (PP) titled, Resident Rights, by failing to: 1. Ensure Resident 1 was given the choice to wear their own clothes instead of a hospital gown. 2. Ensure Resident 1 was given the choice to eat breakfast in the dining room instead of in bed. 3. Ensure Resident 2 was given the choice to wear their own clothes instead of a hospital gown. 4. Ensure Resident 2 was given the choice to eat breakfast in the dining room instead of in bed. These failures caused Resident 1 and Resident 2 to feel dehumanized (deprivation of human qualities).

Inspectors wroteBased on observation and interview, the facility failed to provide a comfortable environment for two of three sampled residents (Residents 1 and 2) based on the facility's policy and procedure (PP) titled, Homelike Environment, by failing to provide pleasant or neutral odors. This failure caused Residents 1 and 2 to feel grossed out by the unpleasant odor and unsanitary.

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate supervision for one of three sampled residents (Resident 3) by failing to: 1. Ensure Resident 3's out on pass (resident temporarily away from the facility) was accurately ordered, documented, and endorsed to the oncoming shift (3 pm to 11 pm shift). 2. Notify Resident 3's Primary Physician when Resident 3 had not returned to the facility on [DATE]. 3. Report the unusual occurrence to the California Department of Public Health (CDPH) based on the facility's PP titled, Unusual Occurrence Reporting, Revised 12/2007. These failures resulted in Resident 3 leaving the facility with Responsible Party (RP) 1 on 10/19/2023 at an unknown time and did not return to the facility until 10/20/2023 at 8:10 am, unaccompanied by RP 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an effective communication method to one of two non-English speaking sampled residents (Resident 3). This failure had the potential to result in resident not receiving necessary care and services.