Western Convalescent Hospital

Inspectors wroteBased on interview and record review, the facility failed to ensure the Family Member (FM 1) of one of three residents' (Resident 3), was notified of the resident's Change of Condition ([COC] a clinical deviation from a resident's baseline). This failure resulted in the resident's responsible party not being aware of the resident's changes/ current skin condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide interventions for the prevention of pressure ulcers (localized damage to the skin and/or underlying tissue usually over a bony prominence) for four of eight sampled residents (Residents 40, 108, 10, and 65) when:Resident 40's and 108's low air loss mattresses (LALM, therapeutic support surfaces designed to prevent and treat pressure ulcers) were not functioning according to manufacturer's guidance. Resident 10's LALM did not have the correct setting. The facility failed to follow its policy and procedure (P&P) titled Wound Care to document Resident 65's wound assessment when doing wound care. These deficient practices placed Residents 40,108, 10, and 65 at risk of developing new pressure ulcers, or developing a worsening condition of their existing pressure ulcers.

Inspectors wroteBased on interview and record review, the facility failed to:Ensure medications were administered as ordered for one of five sampled residents (Resident 40) when:Licensed Vocational Nurse (LVN) 4 administered hydralazine (a blood pressure medication) outside of the ordered parameters on 4/6/2026 and 5/12/2026. LVN 5 failed to administer insulin (a medication to control blood sugar) as ordered on 5/18/2026. Clarify medication orders with the physicians for two of five sampled residents (Resident 103 and 34), when the residents had advanced from intake via gastrostomy tube (G-tube, a flexible medical device inserted directly through the abdomen into the stomach) to being able to take medicine by mouth. Ensure two licensed nurses conducted and signed as witnesses in the destruction of non-controlled medications. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure:Resident 103's food at the bedside was dated and properly stored. One container of baking powder, one container of peanut butter, and one container of beef base in the dry storage area were labeled and dated. Two cabbages with discolored and black markings on edges were not kept in the walk-in refrigerator. These failures had the potential to result in harmful bacteria growth and cross contamination (a transfer of harmful bacteria from one place to another or one object to another) that could lead to foodborne illness (an illness caused by food contaminated with bacteria, viruses, and other toxins) in all of the facility's residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were maintained for two of five sampled residents (Resident 86 and Resident 109). This deficient practice increased the potential for spread of infection among facility residents and staff.

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician obtained informed consent for restraint use for one of one sampled resident (Resident 40). This deficient practice had the potential for Resident 40's Responsible Party (RP 1), to not be fully informed of the risks and benefits associated with restraint use, or to have the opportunity to discuss alternatives to restraints.

Inspectors wroteBased on interview and record review, the facility failed to ensure an interdisciplinary team ([IDT] - team members from different disciplines who come together to discuss resident care) or a Bioethics committee (multidisciplinary group designed to address, analyze, and advise on complex ethical challenges) meeting was conducted prior to initiation of a psychotropic drug (Any drug that affects brain activities associated with mental process and behavior) for one of one sampled resident (Resident 2) who had a diagnosis of Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities). This deficient practice placed Resident 2 at risk for sustaining adverse effects (undesired effect of a drug) from psychotropic medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 73) call light was within reach. This deficient practice of not having the call light within reach had the potential for Resident 73 not to be able to call for assistance.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the belongings for one of five sampled residents (Resident 103) were inventoried and documented. This deficient practice of not keeping track of Resident 103's belongings had the potential to increase the risk of Resident 103 losing her personal items.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their policy and procedure (P&P) titled Use of Restraints, revised 3/2023, for one of one sampled resident (Resident 40) when:Staff placed pillows under Resident 40's fitted bed sheet, on both sides of his body, without an order or consent. Staff failed to document that Resident 40 was assessed for potential physical injury or discomfort while hand mitten restraints (a padded, glove-like medical device used to enclose a patient's hands) were used. This deficient practice restricted Resident 40's movement within his bed and increased the potential for late identification of potential skin breakdown or circulatory issues.

Inspectors wroteBased on interview and record review, the facility failed to ensure a written Notice of Proposed Transfer and Discharge Form was sent to local ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) for one of five sampled residents (Resident 51). This deficient practice had the potential to compromise Resident 51's due process rights related to transfer.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Minimum Data Sets (MDS, a resident assessment tool) were coded accurately for two of 23 sampled residents (Resident 40 and Resident 65). Resident 40's MDS, dated [DATE], did not reflect his use of continuous oxygen therapy, and receipt of intermittent suctioning and tracheostomy care (the routine cleaning and maintenance of a surgically created opening in the neck (stoma) and the inserted breathing tube). Resident 65's MDS, dated [DATE], did not reflect his venous ulcer (slow healing open sore that typically develop on lower leg that is caused by poor blood circulation). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a care plan was developed for one of 23 sampled residents (Resident 40) when Resident 40 did not have a care plan in place for his as needed use of melatonin (an over the counter or prescription pill used to improve sleep issues). This deficient practice prevented staff from having resident-specific non-drug interventions to aid Resident 40's sleep and monitor the effectiveness of his of melatonin.

Inspectors wroteBased on interview and record review, the facility failed to ensure a physician order for gastrointestinal referral (formal request by a physician to send a patient to a gastroenterologist [a medical doctor who specializes in diagnosing, treating, and preventing disease of the digestive system] for testing and work-up) was completed for one of one sampled resident (Resident 98). This deficient practice had the potential to put Resident 98 at risk for worsened gastrointestinal symptoms and delayed diagnosis of underlying medical condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of five sampled residents (Resident 104 and Resident 120) received care in accordance with professional standards of practice when:1. Resident 104 was not monitored for 72 hours after a change of condition ([COC] -any sudden, clinically significant deviation from a patient's normal baseline in their physical, cognitive, behavioral, or functional health status).2. Resident 120's abnormal heart rate was not reported to the physician in a timely manner. These deficient practices had the potential for Resident 104's skin rash (a noticeable change in the color, texture, or appearance of your skin) to worsen due to not being monitored and delayed physician intervention for Resident 120.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe and hazard-free environment for three of three sampled residents (Residents 76, 110, and 37) when:1. Staff did not provide padded side rails as indicated in Resident 76's and 110's respective care plans.2. Staff failed to provide fall mats, as ordered by the physician, for Resident 37. These deficient practices increased the potential for Residents 76 and 110 to sustain avoidable injuries and complications related to missing siderail padding in the event of a seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) and increased the potential for Resident 37 to sustain fall-related injuries.

Inspectors wroteBased on interview and record review, the facility failed to ensure interventions were carried out to prevent malnutrition for one of seven sampled residents (Resident 40) when the facility failed to carry out Resident 40's physician orders for checking prealbumin levels (a specific protein level used to assess acute changes in nutritional status, particularly protein-calorie malnutrition) and a thyroid panel (a group of blood tests used to evaluate how well the thyroid gland is working and to diagnose disorders like hypothyroidism [slowed metabolism] or hyperthyroidism [excessive thyroid hormone that can result in unexplained weight loss]) following Resident 40's 39 pound (lb., a unit of weight measurement) weight loss. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care consistent with professional standards of practice for one of five sampled residents (Resident 40) when:Resident 40 received oxygen therapy at five (5) liters per minute (L/min, a unit of flow rate) without humidification (a method for moistening inhaled oxygen). Respiratory Therapist (RT) 1 did not clarify Resident 40's oxygen order with the ordering provider. These deficient practices placed Resident 40 at risk for discomfort related to irritation of the airways and placed Resident 40 at risk of not receiving oxygen as intended by the physician.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow the physician orders for oxygen administration for one of five sampled residents (Resident 104). This deficient practice caused Resident 9 not to receive the correct oxygen administration.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was provided with medically related social services (services provided by the facility's staff to assist residents in attaining or maintaining their mental and psychosocial health) for an outside gastrointestinal (formal request by a physician to send a patient to a gastroenterologist [a medical doctor who specializes in diagnosing, treating, and preventing disease of the digestive system] for testing and work-up) referral for one of one sampled resident (Resident 98). This deficient practice had the potential to put Resident 98 at risk for delayed medical interventions that would affect her quality of lifeFindings:During a review of Resident 98's Face Sheet, the Face Sheet indicated Resident 98 was originally admitted to the facility on [DATE] and readmitted on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure hydrocortisone (a mild topical corticosteroid used to temporarily relieve itching, redness, and swelling) 1 percent ([%] - a drug percentage expresses the active ingredient in grams per milliliter) medication cream was properly stored for one of one sampled resident (Resident 104). 2. Clarify a pharmacy label with unclear instruction for 1 of 5 sampled residents (Resident 103) when Resident 103's amlodipine bubble pack had a label indicated to take 1 tablet by mouth via G-tube (gastrostomy tube, a flexible medical device inserted directly through the abdomen into the stomach). This deficient practice of not storing the medication after usage had the potential for Resident 104 to unsafely use the medication and had a potential for medication error for Resident 103.

Inspectors wroteBased on interview and record review, the facility failed to implement the physician's order for arterial and venous ultrasounds (painless, non-invasive imaging tests that use sound waves to evaluate blood flow throughout your body) in a timely manner for one of one sampled resident (Resident 65). This deficient practice had the potential to result in the delay of the identification of medical concerns, delaying the care and services necessary for Resident 65.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 9) intravenous peripheral line (IV, a short, flexible catheter inserted into a small vein) dressing was changed every 72 hours to correlate with the documentation on the Medication Administration Records (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to the resident. This deficient practice of not accurately documenting the IV dressing changes had the potential to place Resident 9 at risk for infection at the insertion site.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of two of the trash dumpsters were closed and not overfilled. This deficient practice has the potential to harbor and feed pests.

Inspectors wroteBased on interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for one of three sampled residents (Resident 1), who had a gastrostomy tube (GT-a surgical opening fitted with a device to allow feedings to be administer directly to the stomach common for people with swallowing problems) and tracheotomy ( a surgical opening in the neck fitted with a tube that helps a person breathe), by failing to ensure:1. Resident 1 was not provided with a breakfast tray and did not consume food by mouth without a physician's order. 2. Licensed nurses notified the physician and documented the incident regarding Resident 1 consuming food without a physician's order on 4/21/2026. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of five sampled residents (Residents 2, 3 and 4) who were dependent (relying for support) on staff with activities of daily living, were provided good oral hygiene (the practice of keeping the mouth, teeth, and gums clean and healthy) daily. This deficient practice resulted in the residents' mouth dirty. This deficient practice placed the residents at risk for gum infections and other systemic health infection (bacteria from gum disease that can enter the bloodstream) which can jeopardize the residents' overall health condition, that can lead to hospitalizations.

Inspectors wroteBased on observation, interview, and record review, the facility failed to:1). Implement occupational therapy (OT- a form of therapy for those recuperating from physical or mental illness that encourages rehabilitation through the performance of activities required in daily life) recommendations of hand splints and obtain physician orders for 2 of 5 sampled residents (Resident 2 and Resident 3) to prevent contractures (a medical condition where muscles, tendons, or other tissues become permanently shortened or tightened, limiting movement and causing deformity) of hands and fingers to improve joint mobility. 2). Implement the facility's policy and procedure (P&P) titled Screening, when the Physical Therapist (PT 1) did not reassess one of five residents (Resident 8), after readmission to the facility and after Resident 8 could no longer tolerate his physician-ordered services. [...]

Inspectors wroteBased on interview and record review, the facility failed to report one of three resident's (Resident 7) right thumb fracture (broken bone) to the California Department of Public Health (CDPH) within two hours, as indicated in the Federal regulations. This failure resulted in the delayed investigation by CDPH, placing the affected resident and other residents at risk for potential abuse and injuries.

Inspectors wroteBased on observation, interview and record review, for 1of 5 sample residents, Resident 2, the facility failed to:1). Ensure the intravenous (IV- administration of the medications via a catheter inserted into a vein) medication was administered completely, consistent with professional standards of practice and physician's order.2). Ensure the IV site was securely placed and did not dislodge (pulled out). This failure had the potential for the infection will not be resolved due to an incomplete dose of antibiotic medication administered. This failure had the potential to cause infection on the IV site and the potential for a missed antibiotic dose.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of 5 sampled residents (Resident 2) was administered the correct amount of oxygen (a gas considered as medication essential for life to supplement the body's oxygen supply in conditions), ordered by the physician. This failure had the potential to cause oxygen toxicity (lung damage from breathing in excessive supplemental oxygen [also called oxygen poisoning] causing the resident to cough and trouble breathing and in severe cases, can cause death) to the affected resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three residents' (Resident 8) clinical record contained complete and accurate documentation of the services resident did not receive as indicated in its policy and procedure (P&P) titled Charting and Documentation. This failure had the potential for miscommunication and had the potential that the residents would not receive the quality of care and services the resident need.

Inspectors wroteBased on interview and record review, the facility failed to complete the Physician Orders for Life-Sustaining Treatments (POLST - care directive during life threatening situations, an approach to improve end of life care by encouraging providers to speak with patients and create specific medical orders to be honored by healthcare workers during medical crisis) for one of seven sampled residents (Resident 2). This deficient practice placed Resident 2 at risk for delay in treatment or life sustaining procedures during in the event of an emergency.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1's) transfer to the general acute care hospital (GACH) was documented in resident's medical records. This deficient practice had the potential to place Resident 1 at risk of not receiving appropriate care and delay in communication among staff due to incomplete medical records.

Inspectors wroteBased on interview and record review, the facility failed to ensure a comprehensive care plan for pressure ulcer/injury (PU/PI] - localized damage to the skin and/or underlying tissue usually over a bony prominence) was developed for one of four sampled residents (Resident 2), who had multiple pressure ulcers. This deficient practice had the potential for Resident 2 not receiving the appropriate wound care interventions which could lead to infection or worsening of the wounds.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 2), who had multiple pressure ulcers / injury (PU/PI - localized damage to the skin and/or underlying tissue usually over a bony prominence) received care in accordance with professional standards of practice. Resident 2's PU's were not reassessed weekly including the type of the PU, location, measurement and description. This deficient practice caused an increased risk in the worsening of Resident 2's pressure ulcers and inappropriate or delayed treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure, one of three sampled residents (Resident 1), had a resident-centered, comprehensive care plan. This deficient practice placed the resident at risk for injuries and had the potential for Resident 1 ' s needs to not be met.

Inspectors wroteBased on interview and record review, the facility failed to ensure, one out of three residents (Resident 1), was provided two-persons assist (a care technique where two caregivers work together to help a president with mobility, transfers, or other daily living activities) when providing activities of daily living ([ADLs]-routine tasks/activities such as bathing, dressing, and toileting a person performs daily to care for themselves). This deficient practice placed the resident at risk for falls and injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its infection control program by failing to: 1. Ensure the Laundry Aide (LA) performed hand hygiene, changed gown and gloves after sorting dirty linen and prior to handling clean linen. This deficient practice put all the residents at risk for cross contamination (movement of bacteria from one place to another) and infection. 2. Refrigerate opened food item, as indicated in the bottle container, for one of three sampled residents (Resident 93). This deficient practice had the potential for Resident 93 to experience foodborne illnesses (food poisoning).

Inspectors wroteBased on interview and record review, the facility failed to: 1. Obtain and document informed consent (a process during which residents or caregivers are educated regarding the potential risks and benefits of medication therapy) from the resident or their responsible party (RP - a person delegated to make medical decisions for the resident in the event they are unable to do so) prior to treatment with lorazepam (a medication used to treat mental illness) and sertraline (a medication used to treat mental illness) in one of five residents sampled for unnecessary medications (Resident 83). This deficient practice have prevented Resident 83 or her RP from exercising their right to decline treatment with psychotropic medications. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the room windows were able to close in Residents 23, 55, and 102's rooms ensuring the rooms would not be cold. This deficient practice resulted in the residents being cold while in their rooms.

Inspectors wroteBased on interview, and record review the facility failed to: 1. Ensure one of six sampled residents (Residents 1) received a weekly weight per the physician's order. This deficient practice resulted in inadequate monitoring of the weight of the Resident 2. Ensure one of one sampled resident (Resident 8) had accurate orthostatic blood pressure (a form of low blood pressure that happens when standing after sitting or lying down) readings obtained to determine if the resident had orthostatic hypotension (low blood pressure). This deficient practice had the potential to result in Resident 8 to experience a delay in interventions, if the resident had been positive, for orthostatic hypotension (low blood pressure).

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure the low air loss mattress (a pressure relieving mattress for the management of pressure sores) was at the proper setting to maintain skin integrity for one of 25 sampled residents (Resident 96). 2. Ensure one of six sampled residents (Resident 112) had prevalon boots (cushioned boots used to eliminate pressure on the heels) applied per the physician's order. These deficient practices placed Resident 96 at risk to develop new pressure injury, poor wound healing and deterioration of current pressure ulcers. Resident 112 was at risk for new skin breakdown on the heels of her feet.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide appropriate services to prevent a decline in joint range of motion (ROM, full movement potential of a joint) for six out of 10 sampled residents (Residents 15, 2, 8, 24, 17, and 67) who had limited ROM by failing to: 1) a. Ensure the Restorative Nursing Aide (RNA, nursing aide program that help residents to maintain their function and joint mobility) staff did not put on Resident 15's right elbow splint (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) and right resting hand splint for more than four hours as ordered by the physician. b. Ensure RNA treatment was completed for Resident 15 as ordered by a physician on 2/27/2025, 3/1/2025, 3/8/2025, and 3/16/2025. 2) a. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate and sufficient nursing staff to provide care for residents requiring Restorative Nursing Aide (RNA, nursing aide program that helps residents to maintain their function and joint mobility) treatments. This deficient practice had the potential for 81 residents with physician's orders for RNA to experience a decline in range of motion (ROM, full movement potential of a joint), mobility, and activities of daily living (ADL, basic activities such as eating, dressing, toileting) function. CROSS REFERENCE TO F688.

Inspectors wroteBased on interview and record review, the facility failed to ensure two Licensed Vocational Nurses (LVN) knew what the purpose of checking orthostatic hypotension (a condition where blood pressure drops significantly when a person stands up from a sitting or lying position or sits up from a lying position) was for and how to obtain blood pressure readings, to determine if a resident had orthostatic hypotension. This deficient practice had the potential to place residents at risk for a delay in care and services which could result in falls or injury.

Inspectors wroteBased on interview and record review, the facility failed to monitor blood pressure related to the use of amlodipine (a medication used to treat high blood pressure) with hold parameters (instructions in the medication order to hold the medication if the blood pressure reading is too low) between 3/23/24 and 3/31/24. The deficient practice of failing to monitor blood pressure related to the use of amlodipine increased the risk that Resident 83 could have experienced adverse effects related to receiving amlodipine when her blood pressure was too low possibly resulting in dizziness and falls with injury.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure one of six sampled residents (Resident 1) was not prescribed Seroquel (a drug used to treat a mental health condition) without an appropriate diagnosis. 2. Define and monitor behaviors related to the use with lorazepam (a medication used to treat mental illness) for one of five residents sampled residents (Resident 83). These deficient practices placed Resident 1 and Resident 83 at risk of adverse effects (bad outcome).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure its medication error rate was less than five percent (%). Two medication errors out of 33 total opportunities contributed to an overall medication error rate of 6.06 % affecting two of six residents observed for medication administration (Residents 4 and 83). The facility failed to: 1. Administer the correct strength of cranberry (a supplement) supplement to Resident 4. 2. Administer the correct formulation of multivitamins (a vitamin supplement) to Resident 83. The deficient practices of failing to administer medications in accordance with the physician's orders increased the risk that Residents 4 and 83 may have experienced medical complications possibly resulting in hospitalization.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of four sampled residents (Resident 8) had the correct laboratory tests done as ordered by the physician. This deficient practice had the potential to result in Resident 8 to experience a delay in services due to incomplete laboratory results.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the standardized recipes for the lunch menu was followed on 3/18/2025 by failing to: 1. Ensure Eighteen (18) residents on a soft and bite size diet (Diet for people who are not able to bite off pieces of food safely but are able to chew bite sized pieces down into little pieces that are safe to swallow/Bite sized pieces no bigger than ½ x ½ inches) did not receive whole bread instead of bread that is cut into smaller pieces. 2. Ensure the menu included the texture modified diet (diets that are altered in texture to accommodate resident chewing or swallowing problems includes diets such as Soft and Bite size and Minced and Moist) that was ordered for residents. The menu did not indicate the serving guide for the bread at each meal. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary food preparation practices were followed in the kitchen when one can opener blade was dirty with dry brown sticky residue and when the blade was worn with the potential to spread harbor harmful bacteria. This deficient practice had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to food borne illness in 47 out of 109 residents who received food from the facility.

Inspectors wroteBased on observation, interview, and record review, the facility's policy on food from outside and brought by family-visitors did not address how to store and reheat food to ensure safe and sanitary food storage, handling and consumption. For residents who have leftover food brought from outside the facility, the facility policy does not have a procedure for safe food handling. This had the potential to cause food borne illness in residents in the facility who were served the food brought by family or visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 99) was afforded the right to be free from physical restraint (Bed rails) by failing to: 1. Ensure Resident 99 had an order for the use of bed rails. 2. Ensure Resident 99 had a signed informed consent for the use of bed rails. 3. Ensure Resident 99 was not restrained by having four siderails up. These deficient practices had the potential to result in Resident 99 to experience restricted movement while in bed, and not fully understanding the risks and benefits associated with the use of bed rails which could lead to injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 46), had a diagnosis of diabetes mellitus (DM - a condition that leads to high levels of sugar in the blood), entered on the residents' Minimum Data Set (MDS- an assessment and care screening tool). This deficient practice had the potential to negatively affect Resident 46's plan of care and delivery of necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an extension cord was free from safety hazards for one out of one sampled resident (Resident 96). This deficient practice had the potential to result in an unsafe environment with a fire hazard risk and a risk for fall and injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure its residents were free from significant medication errors by administering amlodipine (a medication used to treat high blood pressure) outside of the hold parameters (instructions in the medication order to hold the medication if the blood pressure reading is too low) a total of 81 times between 4/1/24 and 1/28/25 affecting one of five residents sampled for unnecessary medications (Resident 83.) The deficient practice of failing to administer amlodipine in accordance with hold parameters as specified in the physician order contributed to two falls resulting in injuries to Resident 83's face and hands on 4/10/24 and 6/20/24 and increased the risk that Resident 83 may have experienced other adverse effects of low blood pressure such as dizziness, possibly resulting in a decline in her quality of life.

Inspectors wroteBased on observation, and interview, the facility failed to implement its infection prevention and control measures for two of four sampled residents (Residents 2 and 3) by failing to: 1. Ensure Resident 2's foley catheter ([FC] a thin, flexible tube inserted into the bladder to drain urine) bag was off the floor. 2. Ensure Licensed Vocational Nurse (LVN) 1 and LVN 2 wore Personal Protective Equipment ([PPE] clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) while providing wound care to Resident 2, who was on Enhanced Barrier Precautions ([EBP] an approach to the use of PPE to reduce transmission of Multidrug-Resistant Organisms [MDRO] bacteria that are resistant to multiple antibiotics). 3. [...]

Inspectors wroteBased on observation and interview, the facility failed to provide a safe, clean, and home like environment for 2 of 4 sampled residents (Resident 2 and Resident 4). This deficient practice had the potential to result in unsanitary living conditions, illness and could negatively impact Resident 2 and Resident 4 ' s psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled Residents (Resident 2) was provided a clean homelike environment by failing to provide clean bed sheets. This deficient practice placed Resident 2 at risk for an unclean environment and had the potential for the spread of infection and physical discomfort.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse, for one of 8 sampled residents, (Resident 1), to the California Department of Public Health (CDPH) within two (2) hours, as indicated in the facility ' s policy and procedure (P&P), titled Abuse and Mistreatment of Residents. This failure resulted in the delayed investigation by CDPH and placed Resident 1 at risk for further abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 8 sampled residents (Resident 1), received toileting hygiene in a timely manner. This failure had the potential to cause resident discomfort and skin breakdown.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement infection control practices, by failing to ensure: 1. Oxygen nasal cannulas (a small plastic tube, which fits into the person ' s nostrils for providing supplemental oxygen) were properly stored when not used, for two of eight sampled residents, (Resident 1 and Resident 2). 2. The gastrostomy tube ([GT] a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) site was maintained clean, for two of 8 sampled residents, (Resident 7 and Resident 8). This deficiency had the potential to cause infections to the affected residents.

Inspectors wroteBased on interview and record review, the facility failed to promptly notify the physician of a change of condition (COC) for one of three residents (Resident 1) who was observed with slurred speech (damage to the brain or nerves that cause the muscles used for speaking to become weak and uncoordinated and can be a symptom of a cerebral infarction ([stroke] loss of blood flow to part of the brain). This deficient practice resulted in delayed medical care and had the potential to result in the physical decline and death for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 2 had the specific competencies and skill sets necessary to identify and intervene for a one of three sampled residents who had a change of condition (COC). This deficient practice resulted in delayed care and had the potential to cause harm for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure Midodrine10 mg ([mg] unit of measurement) (medication to treat low blood pressure) was held (not administered) in accordance with the written physician's order for one of three sampled residents (Resident 1.) This deficient practice had the potential to increase Resident 1's blood pressure beyond the normal range (normal range: 90/60 millimeters of mercury [mmHg] to 120/80 mmHg) resulting to complications like stroke.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure the resident's medical records were updated to show documentation of the advance directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) were discussed and written information were provided to the residents and/or responsible parties for six (6) out of (6) sampled residents (Resident 27, 40, 82, 95, 99, and 113). This deficient practice violated the residents' and/or the representatives' right to be fully informed of the option to formulate their advance directives and had the potential to cause conflict with the residents' wishes regarding health care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Keep residents medical records confidential for 3 of 45 residents (Resident 25, 95, and 11). This deficiency violated residents privacy by failing to keep residents' medical records confidential.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Provide treatment and services for two of five sampled residents (Residents 9 and 82) who received gastrostomy tube feedings ([GT] tube surgically placed into the stomach for nutrient and medication administration) to ensure that feeding formula were completely labeled in accordance with the facility's policy and procedure. This deficient practice had the potential to result in Residents 9 and 82 not getting the right infusion rate of the tube feeding formula as ordered by the physician.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Provide treatment and services for two of five sampled residents (Residents 9 and 82) who received gastrostomy tube feedings ([GT] tube surgically placed into the stomach for nutrient and medication administration) to ensure that feeding formula were completely labeled in accordance with the facility's policy and procedure. This deficient practice had the potential to result in Residents 9 and 82 not getting the right infusion rate of the tube feeding formula as ordered by the physician.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure opened food items are stored in a manner to prevent the growth of microorganisms that can cause food borne illnesses (any illness resulting from spoiled or contaminated food). This deficiency had the potential to cause food borne illnesses for resident's in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Develop a care plan for nasal cannula (a device used to deliver supplemental oxygen that should be placed directly on the resident's nostrils) for 2 of 3 sampled residents (Resident 3 and Resident 24). This deficient practice had the potential to result in a lack of meeting necessary care goals and addressing medical needs for Resident 3 and Resident 24.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure the necessary care and services were provided to prevent the reopening of a healed pressure ulcer for one of 22 sampled residents (Resident 101). This deficient practice resulted in Resident 101 obtaining a stage 4 pressure ulcer to the sacrococcyx (area of skin over the tailbone).

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure medications were not left at the bedside for one of one sampled resident (Resident 111). This deficient practice put Resident 111 at risk for health issues related to taking too much medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Implement infection control measures for one of four sampled residents (Resident 68) by failing to wear Personal Protective Equipment ([PPE] gown - specialized clothing or equipment worn by an employee for protection against infectious materials) prior to entering and providing care to Resident 68 on Enhanced Standard Precautions ([ESP] a resident-centered and activity-based approach for preventing Multiple Drug Resistant Organism ([MDRO]-are bacteria that have become resistant to certain antibiotics) transmission in skilled nursing facilities). This deficient practice had the potential to result in cross contamination (physical movement or transfer of harmful bacteria from one person, object, or place to another), spread of infections and placed other residents at risk for infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Implement infection control measures for one of four sampled residents (Resident 68) by failing to wear Personal Protective Equipment ([PPE] gown - specialized clothing or equipment worn by an employee for protection against infectious materials) prior to entering and providing care to Resident 68 on Enhanced Standard Precautions ([ESP] a resident-centered and activity-based approach for preventing Multiple Drug Resistant Organism ([MDRO]-are bacteria that have become resistant to certain antibiotics) transmission in skilled nursing facilities). This deficient practice had the potential to result in cross contamination (physical movement or transfer of harmful bacteria from one person, object, or place to another), spread of infections and placed other residents at risk for infection.