Villa Del Rio

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient staffing when certified nursing assistants (CNAs) were assigned two resident work assignments (assigned residents for the staff member to provide care to). This deficient practice had the potential to result in a delay in care and unsafe care practices.

Inspectors wroteBased on interview and record review, the facility failed to conduct the annual performance evaluation for one of one sampled licensed vocational nurse (LVN 9). This deficient practice had the potential to result in LVN 9 being unaware of any areas in their performance requiring improvement to better care for the residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four staff members (Social Services Coordinator [SSC]), who worked as an uncertified nursing assistant (NA) from 5/1/2023 through 7/31/2024, did not exceed a 4-month employment as an NA and did not perform duties and tasks reserved for certified staff. This deficient practice had the potential for the SSC to provide incompetent care to the assigned residents, which could affect the residents' safety and well-being.

Inspectors wroteBased on interview and record review, the facility failed to conduct the annual performance evaluations for three of three sampled certified nursing assistants (CNAs 4, 5, and 6). This deficient practice had the potential to result in CNAs 4, 5 and 6 being unaware of areas in their performance requiring improvement to better care for the residents in the facilityFindings:1. During a review of Certified Nursing Assistant (CNA) 4's Personal Action Form (PAF), dated 5/6/2022, the PAF indicated the facility hired CNA 4 on 5/6/2022. During a review of CNA 4's Employee File, the Employee File did not contain documentation indicating CNA 4 received an annual performance evaluation from 2023 through 2026.2. During a review of CNA 5's PAF, dated 3/7/2022, the PAF indicated the facility hired CNA 5 on 3/7/2022. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure containers of ground rosemary, ground dill weed, ground oregano, ground chili powder, and a bag-in-box juice dispenser system were labeled with an open date. These failures had the potential for bacterial growth in potentially hazardous foods (PHFs, foods that require strict time and temperature control to prevent the growth of harmful bacteria or the formation of toxins) and increased the risk for food borne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) for 153 residents who consumed food prepared and served from the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to honor three of ten sampled residents' (Residents 5, 34, and 150) right to be informed of and participate in their treatment by failing to: 1. Ensure an informed consent was obtained for Resident 5's use of Olanzapine (medication used to balance brain chemicals to treat mental health conditions such as schizophrenia) and Trazadone Hydrochloride (medication that works to increase serotonin [chemical messenger often associated with mood and happiness] sometimes used as a sleep aid).2. Ensure an informed consent was obtained for Resident 34's use of Celexa (an antidepressant).3. Ensure the name of medications and their indications (reason for the use of the medication) were provided to Resident 150 prior to the administration of the medications. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for six of 12 sampled residents (Resident 15, 30, 48, 78, 89, and 133) by failing to ensure:A clock was present in Resident 15 and Resident 89's rooms. Resident 48 and Resident 133 did not sleep on a bare mattress. Resident 78 had a headboard attached to the resident's bed. The wall behind Resident 30's headboard was kept in good repair. This deficient practice had the potential to negatively impact Residents 15, 30, 48, 78, 89 and 133's well-being and contributed to an environment that did not promote a comfortable and homelike atmosphere for the residents.

Inspectors wroteBased on interview and record review the facility failed to: 1). Ensure the rexulti (a medication used for depression) medication was available on 7/14/2026, 9 a.m. for one (1) of four (4) observed residents (Resident 482), medication administration. 2). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to: Label and store one (1) opened levalbuterol (a medication used to treat chronic obstruction pulmonary disorder [COPD - a condition with shortness of breath, cough and chest tightness]) inhalation (a form of a medication to be inhaled as a vapor or spray) foil pouch (package made of foil protecting the inhalation solution from light and degradation) with an open date for Resident 28, in accordance with the manufacturer's requirements and facility policies and procedures (P&P) in one (1) of three (3) inspected Medication Carts (Medication Cart 2.) 2. Remove and discard from use one (1) expired inhalation treatment for Residents 35 in accordance with manufacturer's requirements in one (1) of three (3) inspected Medication Carts (Medication Cart 2.) 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain documentation of COVID-19 (a contagious respiratory illness) vaccination (a medicine that trains your body to fight off harmful germs or viruses) records and vaccine offerings for three of three sampled residents (Residents 47, 101 and 146). These failures had the potential to result in double dosing (taking or administering two amounts of medication close to the same time) and missed vaccinations for Residents 47, 101 and 146, and increased the risk of COVID-19 outbreaks in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure privacy curtains were installed and privacy was maintained for one out of six sampled residents (Resident 14) when Resident 14's colostomy (a surgical procedure that brings one end of the large intestine out through the abdominal wall to allow waste to leave the body) bag, which was filled with stool (bodily waste), was assessed by the licensed nursing staff. This deficient practice had the potential to result in Resident 14 experiencing a diminished sense of dignity and self-worth.

Inspectors wroteBased on interview and record review, the facility failed to determine the responsible party (RP- an individual appointed to make decisions for an individual without decision-making capabilities) for one of two sampled residents' (Resident 9). This deficient practice resulted in Resident 9 not having an RP who could make medical decisions for her.

Inspectors wroteBased on observation, interview and record review, the facility failed to notify two of two sampled residents' (Residents 135 and 9) physician and responsible party (RP- appointed individual to make medical decisions) of changes in condition by failing to: 1. Ensure Resident 9 had hypotensive (blood pressure below 90 over 60 [90/60] millimeters of mercury [mmHg, a unit of measuring blood pressure]) blood pressure readings taken on 7/5/2026 and 7/14/2026.2. Notify the physician when Resident 135 had bleeding scabs on his forehead on 7/10/2025. This deficient practice had the potential to result in Resident 9 experiencing adverse side effects of hypotension, including dizziness, nausea, and fainting. This deficient practice had the potential to result in Resident 135's wound to go unmonitored, worsen and become infected.

Inspectors wroteBased on interview and record review, the facility failed to verify the Notice of Medicare Non-Coverage Coverage (NOMNC, a form that notifies Medicare residents that their covered services are going to end) and Advance Beneficiary Notice (ABN, a notice notifying that Medicare may deny payment for specific treatments, and provides residents the opportunity to accept or refuse services if Medicare denies payment) forms were signed by someone with decision making capabilities when the Medicare Part A (insurance that primarily covers inpatient skilled nursing facility stays) coverage ended for two of three sampled residents (Resident 24 and Resident 157). This deficient practice resulted in Residents 24 and 157 being unable to make an informed decision about their care.

Inspectors wroteBased on interview and record review, the facility failed to ensure the quarterly Minimum Data Set (MDS, a resident assessment tool) assessments were completed and submitted within the required federal timeframe for four of 24 sampled residents (Residents 44, 46, 47, and 75). The deficient practice had the potential to affect the accuracy and timeliness of resident assessments, care planning decisions, and the facility's compliance with federal Medicare and Medicaid requirements.

Inspectors wroteBased on interview and record review, the facility failed to ensure a fall care plan was revised after a fall for one out of two sampled residents (Resident 135). This deficient practice placed Resident 135 at risk for bodily injury from another fall.

Inspectors wroteBased on interview and record review, the facility failed to conduct the assessments for one of three sampled residents (Resident 38) in accordance with the physician's orders on 6/13/2026. This deficient practice had the potential to result in Resident 38 experiencing undetected adverse reactions of medications, changes of conditions, and abnormal vital signs requiring intervention.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of four sampled residents (Residents 135, 12, and 9) were free of accidents and hazards by failing to:1. Ensure adequate supervision and visual checks were rendered and documented for Resident 135.2. Ensure orthostatic blood pressure (a measurement of the change in blood pressure between lying down and sitting up) orders were followed for Resident 12 for May 2026, June 2026, and July 2026. 3. Ensure Resident 9's orthostatic blood pressure was monitored on 6/13/2026. [...]

Inspectors wroteBased on interview and record review, the facility failed to inform the responsible party for one of seven sampled residents (Resident 30) when Resident 30's initial podiatry appointment (a specialized medical visit to diagnose and treat conditions affecting the feet, ankles) was canceled due to lack of transportation. This deficient practice had the potential to place Resident 30 at risk for delayed diagnosis, treatment and delivery of care.

Inspectors wroteBased on interviews and record reviews, the facility failed to follow the physician-ordered medication parameters for two of two residents (Resident 12 and 9) by failing to: 1. Ensure Lisinopril and metoprolol were not administered outside of the physician-ordered heart rate parameter for Resident 12.2. Ensure Lantus and losartan were not administered outside of the physician-ordered parameters for insulin and blood pressure for Resident 9These deficient practice had the potential to result in adverse outcomes, including hypotension, bradycardia, and hypoglycemia.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medical records were accurate for three of twelve sampled residents (Resident 3, 34, and 135) by failing to: Ensure Licensed vocational nursing staff documented an assessment, monitoring, and treatment for Resident 135's bleeding scab on his forehead. Ensure Resident 34's admission Sheet (Face Sheet, front page of the chart that contains a summary of basic information about the resident) was kept accurate and indicated Resident 34 was self-responsible (able to make his or her own independent medical and lifestyle decisions). Ensure Resident 3 was assigned to the correct room in the electronic health record and physical chart. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that the Arbitration Agreement (is a contract where parties agree to resolve disputes out of a court room) document was executed through an appropriate and informed decision-making process by obtaining the signature of a resident with impaired cognitive status without involving or consulting the resident's daughter, who was identified by the facility as the emergency point of contact, for one of three residents sample residents (Resident 32). This deficient practice had the potential to result in the resident signing a legally significant document without fully understanding its contents, purpose, or implications, thereby compromising the resident's ability to make an informed decision and placing the resident's rights and interests at risk.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow its Infection Prevention and Control measures for one of three sampled residents (Resident 7) by failing to identify, clean, and disinfect urine contamination in Resident 7's room. This deficient practice had the potential to create unsanitary living conditions, attract pests, increase the risk of infection, produce offensive odors, and negatively affect the resident's comfort, dignity, and quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one out of three sampled residents' (Resident 1) belongings were listed in the residents belonging inventory (a process which of all the resident's items were listed) on readmission. This failure had the potential for the resident's belongings to be lost or stolen and the potential to violate the resident's right to a safe environment .

Inspectors wroteBased on interview and record review, the facility failed to: 1). Follow its policy and procedure (P&P) titled, Bed Hold (reserving resident's bed for 7 days while temporarily away from the facility, such as during hospitalization or therapeutic visits) Notice, which indicated to provide written information to the resident and/or the resident representative (RP) regarding bed hold practices both well in advance, and at the time of transfer, hospitalization or therapeutic leave.2). Offer the facility's first available bed to one of three sampled residents (Resident 1), who was hospitalized and ready to return to the facility after the seven (7)-day bed hold period. These failures resulted in violating the resident's right to be permitted to return in the facility's first available bed on 6/17/2026.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Facility Assessment, which indicated, the facility assessment should be reviewed and updated as necessary whenever there is any change that would require a substantial modification to any part of the assessment, when the facility did not have a contracted Respiratory Therapy ([RT], a specialized healthcare where practitioners are trained in pulmonary [relating to the lungs] medicine to work with people suffering from pulmonary disease) in the building. This failure had the potential for the facility not to provide adequate care and services to residents requiring RT services.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure (P&P) for discharge against medical advice (AMA) for one of one sampled resident (Resident 1) when Resident 1 left the faciity on 5/22/2026. This deficient practice had the potential to place Resident 1 at risk for unmet care needs, continuum of care, and adverse health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 1 accurately and timely documented a resident's aggressive behavior for one of three sampled Residents (Resident 1). This deficient practice had the potential to result in incomplete communication among staff regarding Resident 1's behavior status, delayed assessment, and the provision of care and/or interventions for the resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of three sampled residents (Residents 2 and 3) received treatment and care in accordance with professional standards of practice by failing to:Ensure Licensed Nurses administered treatment for Resident 2's Candidiasis (common fungal skin infection characterized by a bright red, itchy rash) as ordered by the physician. Ensure the physician was notified and treatment orders were obtained when Resident 3 reported an itchy rash to the groin area on 1/31/2026. These failures placed Residents 2 and 3 at risk for discomfort, worsening skin conditions and hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the plan of care was re-evaluated and revised for one of three sampled residents (Resident 1) who had on-going rash with complaints of itchiness. These failures had the potential to result in Resident 1 not receiving the necessary care and placed Resident 1 at risk for discomfort, physical decline and worsening skin condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, one of three residents (Resident 2), was provided with an appropriate call light (an equipment used when calling for staff when assistance is needed) to use. This deficient practice resulted in the resident's feeling of being ignored and neglected, and the potential for the resident not being able to call for help when assistance is needed, and needs will not be met.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician and obtain an order to implement, when one of three sampled residents (Resident 1), was readmitted to the facility with a rash on bilateral (both) lower extremities (BLE, arms or legs). This deficient practice resulted in delayed treatment and could have led to worsening of rash.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control measures, for one of three residents (Resident 2) by failing to:1). Perform hand hygiene before putting on gloves (a personal protective equipment used when providing resident care).2). Remove used contaminated gloves prior to placing a clean diaper and clean linen and before touching Resident 2. These deficient practices had the potential to result in cross-contamination (process by which bacteria or other microorganisms are unintentionally transferred from one object or person to another, with harmful effect), severe infection and hospitalization.

Inspectors wroteBased on observation and interview, the facility failed to ensure two of three sampled residents (Resident 1 and 2) rooms were equipped with functional ceiling suspended curtains. This deficient practice violated Resident 1 and Resident 2's rights to full visual privacy. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 1's diagnoses included anxiety disorder (mental health condition characterized by excessive worry, fear and nervousness that can interfere with daily life), paranoid schizophrenia (a mental illness that is characterized by disturbances in thought), muscle wasting and atrophy (loss of muscle tissue, causing muscles to shrink and weaken), and lack of coordination. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to meet professional standards in preparing and administering medications to three of the five sampled residents' (Residents 1, 2, and 3). This deficient practice had the potential to violate residents' rights and placing the affected residents at risk for drug interactions.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure, two of seven sampled residents, (Residents 6 and 7), were provided with a safe, clean and home-like environment. This deficient practice had the potential to result in violation of residents' rights.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of six sampled residents' (Resident 5) antipsychotic medication (medication that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior), which was given on an as needed basis (PRN), did not exceed 14 days. This deficient practice resulted in the lack of evaluation of Resident 5's medication.

Inspectors wroteBased on interview and record review, the facility failed to complete and retain documentation of Background Reports for five of six sampled staff members (Registered Nurse [RN] 2, Licensed Vocational Nurse [LVN] 2, LVN 4, Treatment Nurse [TN] 1, and Certified Nursing Assistant [CNA] 2) in a timely manner. This deficient practice had the potential for RN 2, LVN 2, LVN 4, TN 1, and CNA 2's's undetected history of abuse, neglect, exploitation, or misappropriation of resident property, if any, and to allow access to the residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their policy and procedure titled Enteral Feedings-Safety Precautions to ensure one of four sampled residents, Resident 2 was in an upright 30-degree position during gastrostomy tube (G-tube- is a tube inserted through the belly that brings nutrition directly to the stomach) feeding. This failure had the potential to result in aspiration (occurs when food or liquid is breathed into the airways or lungs, instead of being swallowed), difficulty breathing, infections and impede progress to wellness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 2 and LVN 5 explained the medications being administered to two of three sampled residents (Resident 9 and 10). This deficient practice had the potential to result in Resident 9 and 10 not knowing what medications were administered to them.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1), who was assessed as at risk for elopement (the act of leaving a facility unsupervised and without prior authorization) and diagnosed with paranoid schizophrenia (a mental illness that was characterized by disturbances in thought), chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), hypertension (HTN- high blood pressure), and epilepsy (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) did not leave the facility through an unlocked and disarmed door, by failing to: 1. Supervise Resident 1's whereabouts who had behaviors of wandering to the exit door and waiting by the front door. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices by not ensuring the shower room and toilet was clean after use. These deficient practices resulted in an unsanitary environment that increased the risks of infection among residents and staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, sanitary, and comfortable environment for residents when the following occurred: 1. Six out of the eight Geri chairs (specialized chair designed to provide comfortable and supportive seating for individuals with limited mobility) were broken and/or ripped in Building A. 2. Two out of the eight shower chairs were broken and/or ripped in Building A. These deficient practices resulted in an unsafe and uncomfortable environment that increased the risk of injury among residents and staff.

Inspectors wroteBased on interview and record review, the facility failed to implement the care plan for one of three sampled residents (Resident 3) by failing to monitor the effectiveness of treatment for the resident's rash. This failure had the potential for Resident 3's rash to worsen and lead to the resident's physical and psychosocial needs not being met.

Inspectors wroteBased on interview and record review the facility failed to ensure pain management was effective for one of three sampled residents (Resident 3) by failing to: 1. Reassess Resident 3's pain after administering Hydrocodone-Acetaminophen (Norco- a medication used to relieve pain), in a timely manner on 5/26/2025. 2. Reassess Resident 3's pain after administering Norco on 5/27/2025. These failures had the potential to result in unresolved pain for Resident 3 and could negatively affect the resident's physical and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure Licensed Vocational Nurse (LVN 5) documented the administration of Hydrocodone-Acetaminophen (Norco-a medication used to relieve pain) for one out of three sampled residents (Resident 3). This failure placed Resident 3 at risk for medication errors, drug overdose and could lead to adverse drug events for the resident.

Inspectors wroteBased on interview and record review, the facility failed to provide a refrigerator to store residents' food brought from visitors. This deficient practice resulted in staff disposing of residents' leftover food brought from visitors that could have been stored in a refrigerator.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control measures were implemented and/or maintained for 13 of 158 residents (Residents 58, 8, 87, 17, 84, 48, 114, 28, 22, 215, 90, 82, and 2) when the following occurred: 1. Enhanced barrier precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs, bacteria that are resistant to three or more classes of antimicrobial drugs]) were not implemented for 12 residents (Residents 58, 8, 87, 17, 84, 48, 114, 28, 22, 215, 90, and 82) who met the requirements for EBP. 2. Facility failed to maintain and implement a water management system (the facility's plan and activities for reducing risk of Legionella [a bacteria that can cause illness in the lungs and flu-like illness] and other opportunistic pathogens). 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) prior to administration of psychotropic medication (medications that affect the mind, emotions, and behavior) for five of seven sampled residents (Residents 41, 122, 114, 45, and 109) by failing to: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS, a resident assessment tool) assessments for 5 of 32 sampled residents (Residents 82, 159, 39, 74, and 59) were completed and documented accurately. This deficient practice resulted in the transmission of inaccurate data to the Centers for Medicare and Medicaid Services (CMS) regarding the above residents' health status and unique healthcare needs. This deficient practice also created the potential for the above residents to not receive the care and interventions needed to reach their highest practicable physical and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident-centered care plans were developed and implemented for seven of 32 sampled residents (Residents 70, 41, 122, 59, 101, and 114). This deficient practice placed Residents 70, 41, 122, 74, 59, and 101 at risk of not receiving care and resident-centered interventions to meet and address their needs.

Inspectors wroteBased on interview and record review, the facility failed to review and revise the care plan for three of 18 sampled residents (Residents 134, 114, and 104), by failing to: 1. Revise Resident 134's care plan (a document that helps nurses and other team care members organize aspects of resident care) and interventions (actions a nurse takes to implement a care plan, intend to improve the resident's comfort and health) after Resident 134 had an unwitnessed fall on 12/18/2024. This deficient practice had the potential to result in Resident 134 sustaining a major injury after another fall. 2. Ensure the Interdisciplinary Team (IDT) meeting was held quarterly and after Resident 114 was sent to the GACH (General Acute Hospital (GACH)) due to bleeding gums. [...]

Inspectors wrote3. During a review of Resident 28's admission Record (Face Sheet), the Face Sheet indicated Resident 28 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included encephalopathy (a disorder or disease of the brain, often affecting its ability to function properly), multiple sclerosis (a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord), and a Stage four pressure ulcer (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) on the right buttock. During a review of Resident 28's History and Physical (H&P), dated 3/11/2024, the H&P indicated Resident 28 could make needs known but could not make medical decisions. During a review of Resident 28's MDS, dated [DATE], the MDS indicated Resident 28's cognition was moderately impaired. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safety was maintained for three of five sampled residents (Resident 82, Resident 134, and Resident 2) by failing to: 1. Ensure Resident 82's call light was maintained within reach, and ensured Resident 82 was wearing non-slip footwear, as indicated in his fall risk care plan. 2. Ensure an Interdisciplinary Team ([IDT], a coordinated group of experts from several different fields) meeting was conducted after Resident 134 had an unwitnessed fall on 12/18/2024. 3. Ensure Resident 2, who had dysphagia (difficulty swallowing) did not eat from another resident's tray. These deficient practices placed Residents 82 and 134 at risk for falls and subsequent injuries. [...]

Inspectors wroteBased on observation, interview, and record review, the Rehabilitation Department failed to perform formal physical therapy (PT) and occupational therapy (OT) evaluations (PT evaluations to assess a person's movement, strength, and range of motion. OT evaluation focuses on how those physical and cognitive skills impact daily activities) as ordered by the physician to prevent decline and maintain the functional status and, or functional levels for two of six sampled residents (Resident 114 and Resident 28). These failures resulted in a year-long delay of the initiation of treatment and services to prevent decline and maintain the functional status and levels of Resident 114 and Resident 28. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Complete and timely submit the referral for probate conservatorship application (referral to the court to appoint a conservator [an appointed person to act or make decisions for a person who cannot make decisions for themselves]) for two of 13 sampled residents (Residents 114 and 41), whom did not have the capacity to make decisions. This deficient practice resulted in a delay in the process of obtaining a conservator, a lack of sound oversite of Resident 114 and 41's medical care and treatments, and improper notification of changes. 2. Ensure the Minimum Data Set (MDS, a resident assessment tool) reflected Resident 159's and Resident 39's preference to use an interpreter, and Resident 39's preferred language of Cantonese. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote respect and dignity by failing to ensure dentures were provided for one of six sampled residents (Resident 40). This deficient practice negatively impacted Resident 40's quality of life and resulted in feelings of embarrassment due to her appearance and inability to chew her food.

Inspectors wrote2. During a concurrent observation and interview on 4/21/2025 at 12:22 p.m., with Resident 2, observed Resident 2 sitting in her wheelchair next to her bed. Resident 2's call light device was observed hanging on the wall behind the head of the bed and out of reach of the resident. Resident 2 asked for something to eat. Resident 2 was asked if she was able to reach her call light. Resident 2 stated that she could not reach her call light and asked if the nurse could be called. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of six sampled residents' (Resident 154) Advance Directive (a legal document indicating resident preference on end-of-life treatment decisions) Acknowledgement form (form that indicates whether an individual has an Advance Directive or if an Advance Directive would like to be formulated) was accurately completed. This deficient practice resulted in an inaccurate and incomplete Advance Directive Acknowledgement and had the potential to result in confusion whether Resident 154 had an Advance Directive and if not, if Resident 154 wanted to formulate one. This deficient practice placed Resident 154 at risk of not receiving necessary care based on Resident 154's wishes.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's public guardian (PG- an appointed individual that is responsible for the care of individuals who are no longer able to make decisions or care for themselves) or responsible party (RP), and physician were notified when two of nine sampled residents exhibited a change of condition (Residents 114, and 104) by failing to: 1. Ensure Resident 114's PG or RP were notified when the resident exhibited a change of condition and was transported to the General Acute Care Hospital (GACH). This deficient practice resulted in the delay of proper verification of Resident 114's appointed RP or PG, which led to a lack of RP or PG notification when Resident 114 exhibited a change of condition and was sent to the GACH 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services to maintain good grooming and personal hygiene for one of six sampled residents (Resident 125) by failing to keep the resident's fingernails clean and neat. This failure had the potential to result in a negative impact on Resident 125's quality of life and self-esteem and had the potential to result in the development of an infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper hand-off / shift report (a process where nurses exchange vital patient information between shifts to ensure continuity of care and patient safety) was provided between nursing staff for one of six sampled residents (Resident 8). This deficient practice resulted in Resident 8 being exposed while in bed and left covered in feces.

Inspectors wroteBased on interview and record review, the facility failed to ensure post-dialysis monitoring was conducted after one of one sampled resident (Resident 82) returned from hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed). This deficient practice had the potential to place Resident 82 at risk for unidentified complications following hemodialysis, such as bleeding from the hemodialysis access site and low blood pressure.

Inspectors wroteBased on interview and record review, the facility failed to develop a care plan for dementia (a progressive state of decline in mental abilities) for two out of six sampled residents (Residents 41 and 101). This failure had the potential to result in inappropriate care and delivery of medical services provided to Resident 41 and Resident 101.

Inspectors wroteBased on interview and record review, the facility failed to provide behavior monitoring for two of five sample residents (Residents 134 and 41) who received psychotropic medications (medication that affect the brain and alters mood, thoughts, emotions, and behaviors) by failing to: 1. Monitor Resident 134's behavior of yelling and screaming at others for no reason. 2. Monitor Resident 41's behavior of screaming. These deficient practices had the potential to result in the inaccurate assessment of the effectiveness of Residents 134 and 41's medication regimen.

Inspectors wroteBased on interview and record review, the facility failed to follow the parameters for administering Glucotrol ([Glipizide] - lowers sugar levels in the blood) for one of six sampled resident (Resident 60). This deficient practice had the potential to cause hypoglycemia (low blood sugar [BS]) levels for Resident 60.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 144) was offered a pneumococcal vaccine (an injection that protects against pneumococcal disease, which is caused by Streptococcus pneumoniae bacteria). This deficient practice had the potential to place Resident 144 at risk for contracting pneumococcal disease (e.g. pneumonia [an infection/inflammation in the lungs]) and suffering potential death.

Inspectors wroteBased on interview and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 1 was provided with abuse prevention, identification, and reporting training prior to providing direct care to facility residents. This deficient practice placed facility residents at risk of not having their allegations of suspected abuse being identified and/or reported by LVN 1, as required by the facility's policy and procedure.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a plan of care for a resident that was at risk of elopement (the act of leaving a facility unsupervised and without prior authorization) for one of two residents (Resident 1). This deficient practice had the potential to delay the delivery of necessary care and services to minizine the risk of elopement.

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision for one of two residents (Resident 1) who were at risk of elopement (the act of leaving a facility unsupervised and without prior authorization) when Resident 1 eloped from the facility on 1/15/2025. This deficient practice had the potential to negatively affect Resident 1's physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure water temperatures for 3 of 6 resident restrooms (Rooms 66, 92 and 93) and one shower room did not exceed above 120 degrees Fahrenheit (deg f). This deficiency had the potential to cause burns (to injure by exposure to heat) for facility residents sharing the restroom sinks and shower room.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was provided a safe, functional, and comfortable environment by failing to ensure: 1. Resident 1 had a working bathroom sink with hot water. 2. Resident 1 ' s bathroom sink did not leak water onto the floor. This deficient practice caused Resident 1 to feel uncomfortable and had the potential to cause slips, falls for the resident and negatively affect the resident ' s psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) had a representative acting on her behalf by failing to: 1. Ensure Resident 1's Responsible Party (RP) 1's telephone number was indicated on Resident 1's Face Sheet. 2. Seek RP 1's telephone number after Resident 1 had a fall on 6/21/2024 and 8/7/2024. 3. Refer Resident 1 to the Public Guardian (an appointed person who manages the property, finances, and personal care of a person who was unable to properly care for themselves) when RP 1 was unable to be contacted. These deficient practices resulted in RP 1 being unaware of Resident 1's falls and unable to participate in any decision-making regarding Resident 1's care. This deficient practice also resulted in Resident 1 not having a care representative who was actively involved in her care. Cross reference F580.

Inspectors wroteBased on interview and record review, the facility failed to contact a resident's Responsible Party (RP) 1 for one of three sampled residents (Resident 1) after Resident 1 fell on 6/21/2024 and 8/7/2024. This deficient practice resulted in RP 1 being unaware of Resident 1's fall incidents and unable to participate in any decision-making regarding Resident 1's care. Cross reference F551.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, Resident Examination and Assessment, which indicated the facility will assess a resident for any abnormalities in health status, such as abdominal distention, pain duration, severity and factors that worsen the pain, for one of three sampled residents (Resident 65), when Resident 65 complained of severe abdominal pain on 8/24/2024 at 11:00 p.m. and on 8/25/2024 at 2:30 p.m. This failure caused Resident 65 to be emotionally distressed (angry, scared, and frustrated), suffer severe pain for an extended period and was transferred to a general acute care hospital (GACH) for evaluation and treatment.

Inspectors wroteBased on interview and record review, the facility failed to provide pressure ulcer (damaged skin caused by staying in one position for too long) treatments as ordered by the physician for three of three sampled residents (Resident 83, Resident 16, Resident 9). This deficient practice had the potential to result in skin infections, delayed wound healing and worsening of pressure ulcers.

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient nursing staff to ensure quality nursing care are rendered to the residents in the facility and ensure all medications were administered as ordered by the physician to the 3 of 3 sampled residents (Residents 65, 8 and 83). This failure had the potential to providing poor-quality resident care and services, which can affect in maintaining the highest practicable physical, mental, and psychosocial well-being of the residents under the facility ' s care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. Staffing information was including the actual number of hours worked by nursing staff, was completed, current and posted for two days. 2. Staffing data was readily available upon request. These failures had the potential for resident, staff and visitors to be unaware of the accurate number of clinical staff taking care of residents daily to meet the resident ' s needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure nursing staff closed the privacy curtain for four of ten sampled residents (Resident 5, Resident 6, Resident 7, and Resident 8) while receiving Activity of Daily Living (ADL) care. This deficient practice violated the resident's right for privacy and had the potential to affect the self-esteem, self-worth, and psychosocial well-being of Residents 5, 6, 7, and 8.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain residents' room temperature in a range of 71- and 81-degrees Fahrenheit (° F) for three resident rooms (rooms [ROOM NUMBER]). This deficient practice placed the residents in the affective rooms at risk for hyperthermia (overheating), dehydration (body loses too much fluid and sodium [salt]) and heat stroke (life-threatening heat-related illness that occurs when the body rises to a dangerous level and cause dizziness, confusion, and loss of consciousness).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide one of ten sampled residents (Resident 1) proper incontinence care when a towel was left inside the resident ' s adult brief. This deficient practice had the potential to cause skin breakdown and infection to Resident 1. Findings During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), acute respiratory failure (a condition that makes it difficult to breathe on your own), and cerebral infarction (damage to brain tissues due to a loss of oxygen in the area). [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Abuse, Neglect, and Exploitation which indicated the facility should report allegations of abuse immediately, but no later than two hours. This failure delayed the investigation by the California Department of Public Health (CDPH).

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate supervision was provided for one of three sampled residents (Resident 1), after a physical altercation with Resident 2 and Resident 3. This deficient practice led to Resident 1 striking out at Resident 2 and Resident 3, and caused Resident 2 to develop a contusion (a bruise as aresult of a direct blow or an impact) on her forehead.

Inspectors wrote2a. A review of Resident 113's admission Record (Face Sheet), indicated Resident 113 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included but not limited to muscle wasting and atrophy (decreased muscle size), major depressive disorder (mood disorder), and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A review of Resident 113's MDS, dated [DATE], indicated Resident 113's cognition was moderately impaired. The MDS indicated Resident 113 required substantial assistance sitting to standing, toilet transfers and bed to chair transfers. A review of Resident 113's Physician Orders, dated 3/1/2023, indicated that Resident 113 was to receive RNA for passive range of motion to bilateral upper and lower extremities as tolerated daily, five times a week. 2b. [...]

Inspectors wroteBased on interview and record review, the facility's Quality Assessment and Assurance Committee (QAA, the coordinated application of two mutually-reinforcing aspects of quality management system, taking a systemic interdisciplinary, comprehensive, and data-driven approach to maintaining and improving safety and quality) failed to monitor and ensure abuse allegations were reported within two hours to the State Survey Agency (Department of Public Health), the ombudsman, and the police department) prior to conducting a thorough investigation. This deficient practice placed the facility's residents at risk for not receiving the quality treatment necessary to adequately meet their highest practicable well-being. Cross Reference F600, F609, and F610.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement an effective infection prevention control program for 12 out of 12 sampled residents (Resident 10, 30, 35, 53, 54, 81,91, 117, 131, 209, 360, and Resident 361) when the facility failed to ensure the following: 1. Implement and maintain an effective infection surveillance program for Resident 10, Resident 30, and Resident 209. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and maintain an effective antibiotic stewardship program for three out of six sampled residents (Residents 10, 30, and 209). These deficient practices had the potential for Residents 10, 30, and 209 to be administered and prescribed antibiotics inappropriately and unnecessarily. Cross reference F880.

Inspectors wroteBased on interview and record review, the facility failed to implement and maintain an effective abuse training program when the facility did not ensure the following: 1. Ensure all Certified Nursing Assistants (CNA), Licensed Vocational Nurses (LVNs), and Registered Nurses (RNs) were in-serviced on abuse. 2. Ensure the correct information regarding abuse reporting was taught to the attendees of the in-services. These deficient practices led to the under reporting of incidences and allegations of abuse and had the potential to lead to further abuse and harm for all residents within the facility. Cross reference F600, F609, and F610.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the two of 19 sampled residents (Resident 460 and 131), from abuse by failing to: 1. Ensure Resident 460 was free from Resident 156's physical abuse. 2. Protect Resident 131 from Resident 209's verbal abuse. These failures had the potential to lead to another physical altercation between Resident 156 and Resident 460, Resident 156's inflicting physical harm or serious bodily injury toward the other residents residing in Building B, and Resident 209's continued and intensified abuse toward Resident 131.

Inspectors wroteb. A review of Resident 156's admission Record (Face Sheet), the admission Record indicated Resident 156 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but not limited to metabolic encephalopathy (a problem in the brain), hypertension (high blood pressure), major depressive disorder (mood disorder), and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A review of Resident 156's MDS, dated [DATE], indicated Resident 156's cognition was severely impaired. The MDS indicated Resident 156 needed moderate assistance when performing toileting hygiene, showering, and bathing and lower body dressing. The MDS indicated Resident 156 required supervision when eating and performing personal hygiene. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide evidence that abuse allegations were thoroughly investigated and failed to implement interventions to prevent further potential abuse for three of 33 sampled residents (Residents 32, 410, and 55) when: 1. Resident 32 expressed to the facility's staff that she was sexually abused (non-consensual contact of any kind). 2. Resident 55 alleged Resident 410 hit Resident 55 on the nose. These deficient practices had the potential to result in unidentified abuse in the facility and failure to protect residents from further potential abuse. Cross Reference F600, F609, and F943.

Inspectors wroteBased on interview and record review, the facility failed to ensure the quarterly Minimum Data Set (MDS, a standardized screening and assessment tool) were completed within the required time frame for seven of 19 residents (Residents 19, 29, 38, 39, 105, 142, 157). This deficient practice had the potential to negatively affect the provision of necessary care and services provided to each resident.

Inspectors wroteBased on interview and record review, the facility failed to accurately assess the functional limitation (limited ability to move a joint that interferes with daily functioning) in range of motion [ROM, full movement potential of a joint (where two bones meet)] of both arms for one of six sampled residents (Resident 91) with limited ROM and mobility (ability to move) on 1/12/2023, 4/13/2023, 7/13/2023, 10/12/2023, and 1/11/2024. This deficient practice prevented Resident 91 from receiving services to improve ROM and provided inaccurate information to the Federal database. Cross reference F688.

Inspectors wroteDuring an observation, interview, and record review, the facility failed to ensure staff provided the necessary care and services for two out of eight sampled residents (Resident 10 and Resident 53) that were bedridden by failing to: 1. Ensure Resident 10 and Resident 53 were repositioned every two hours. 2. Ensure Resident 10 and Resident 53 were offered to get out of bed. 3. Ensure Resident 10 and Resident 53 were up out of bed when requested. These deficient practices had the potential to cause a negative impact on Resident 10 and 53's health and psychosocial well-being by not meeting the resident's needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure three out of eight sampled residents (Resident 79, Resident 103, and Resident 137) were seen by an optometrist (healthcare provider that examines, diagnoses, and treats diseases and disorders that affect eyes and vision). This deficient practice could have potentially caused a delay in treatment for Resident 79, 103, and 137.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free of accidents and hazards by failing to: 1. Ensure adequate supervision was provided to ensure safety and prevent accidents and/or hazards for five of five residents (Residents 17, 70, 77, 97, and 159) were unsupervised in the smoking patio. 2. Ensure residents did not have access to the Library Room, which had a ceiling leak, to prevent accidents and hazards. These deficient practices had the potential in an unusual occurrence or accident, such as an unwitnessed fall, a resident-to-resident altercation, elopement (leaving an institution without notice or permission) and/or other physical injuries.

Inspectors wroteBased on observation, interview, record review, the facility failed to: 1. Ensure availability of Famotidine (a medication used to treat heartburn, acid indigestion and gastroesophageal reflux disease [GERD - a short medical term for a condition when stomach acid flows back into esophagus [the tube connecting mouth and stomach]) for one of four residents (Resident 98) during medication administration. This deficient practice had the potential to result in worsening of GERD symptoms and adverse consequences such as esophagitis, ulcer (medical term for a sore), bleeding complications and hospitalization. 2. Maintain and provide documentation of disposition of controlled medications. [...]

Inspectors wroteBased on observation, interview, record review, the facility failed to ensure the removal of undated and/or expired insulin (a medication used to treat high blood sugar), Fluticasone-Salmeterol inhalation device (a medication delivered in the form of inhalation powder through a device to treat breathing problems), and Latanoprost ophthalmic (a medical term for eye) solution (a medication in form of eye drops to lower eye pressure), per manufacturer's requirements affecting nine residents (Residents 43, 61, 70, 72, 79, 86, 95, 102 and 559) in three of five inspected medication carts (Medication Cart 2C, Medication Cart 3C and Medication Cart 1G). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe and sanitary food storage practice in the kitchen that affected 168 residents out of 168 sampled residents when: 1. The dry storage room contained opened food items with no use by date (date the food item must be consumed by). 2. The freezer contained food with no in date (the date when the food was placed in the freezer) and no use by date. 3. The walk-in refrigerator had a tray with pork labeled with an unidentified date of 4/14/2024. 4. The walk-in refrigerator contained food with no in date and no use by date. 5. Dietary staff did not check food temperatures before serving food to residents. 6. The ice machine in the kitchen was not cleaned. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess the need for modifications to the call light system for one out of 13 rooms (Room A) by failing to: 1. Ensure the call light for Bed A, Bed B, and Bed C lit up outside of the room when activated. 2. Ensure Certified Nursing Assistant (CNA) 14 reported the need for a call light repair in the maintenance repair logbook. These deficient practices had the potential to result in a delay in obtaining necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide special accommodations to the call light system for one of eight sampled residents (Resident 30). This deficient practice resulted in Resident 30 being unable to use the call light for assistance resulting in Resident 30 calling out loud for assistance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the primary physician of the change in condition (major decline or improvement in a resident's status that will not resolve itself without intervention) for one of six sampled residents (Resident 91) with limited range of motion [ROM, full movement potential of a joint (where two bones meet)] and mobility (ability to move) by failing to notify the physician of Resident 91's ROM decline in both arms and both legs on 3/27/2024. This deficient practice resulted in Resident 91 not receiving services to improve ROM and mobility. Cross reference F688.

Inspectors wroteBased on interview and record review, the facility failed to develop and/or implement an individualized person-centered plan of care with measurable objectives, timeframe, and interventions to meet the residents' needs for one out of eight sampled residents (Resident 410). This deficient practice had the potential for Resident 410 not to receive individualized care and treatment to meet the resident's mental and psychosocial needs.

Inspectors wroteBased on interview and record review, the facility failed to develop a person-centered care plan (document that helps nurses and other team care members organize aspect of resident care) for one of 7 sampled residents (Resident 32) who had a sexual abuse allegation. This deficient practice had the potential to negatively affect the delivery of necessary care and services for Resident 32. Cross Reference F609 and F610.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Revise the Restorative Nursing Aide (RNA, certified nursing aide program that helps residents to maintain their function and joint mobility) care plan since 2/2023 for one of six sampled residents (Resident 91) with limited range of motion [ROM, full movement potential of a joint (where two bones meet)] and mobility. This deficient practice resulted in Resident 91 not receiving the care and services needed to prevent a decline in ROM and mobility. Cross reference F688. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to date the oxygen and nebulizer (a small machine that turns liquid medicine into a mist that can be easily inhaled) delivery systems for one out of three residents (Resident 360). This deficient practice had the potential to cause infection for Resident 360.

Inspectors wroteBased on observation, interview, and record review, the facility's dietary staff failed to ensure a resident, who had a history of dysphagia (difficulty or discomfort in swallowing) and was edentulous (without teeth), was served the correct prescribed therapeutic diet for one out of eight sampled residents (Resident 69) This deficient practice had the potential for Resident 69 to choke on his food.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one out of three sampled resident ' s (Resident 3) was provided a homelike environment by failing to ensure missing and broken blinds on Resident 3 ' s sliding glass door was replaced or repaired. This failure had the potential to violate Resident 3 ' s right to privacy and negatively affect Resident 3 ' s comfort by not being able to properly adjust the amount of sunlight that entered the resident ' s room.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two resident beds (bed A) in room [ROOM NUMBER] was in a safe, operating condition. This failure had the potential to result in a resident being assigned to a bed that did not work and interfere with patient care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection control and prevention program by failing to: 1. Implement proper infection prevention and control interventions for one of 15 residents, (Resident 1), who was positive for coronavirus virus (COVID-19, a highly contagious viral infection). Resident 1 walked out of her isolation room, grabbed a cup from the top of the facility's medication cart and touched other clean medical supplies on the left side of the medication cart without staff intervention. 2. Ensure three of the 15 COVID-19 positive residents (Residents 1, 2, and 3) did not co-mingle with the five COVID-19 negative residents (Residents 4, 5, 6, 7, and 8) who were smoking in the patio with staff supervision. 3. Report the facility's COVID-19 positive cases to the Department of Public Health Licensing and Certification. [...]