California Healthcare and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at California Healthcare and Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF600Feb 7, 2022

  Based on interview, and record review, the facility failed to follow its policy and procedures on resident abuse for one of three sampled residents (Resident 1). On 10/7/2021, the facility was made aware the transportation driver was tying Resident 1 up in the wheelchair during the transportation from and to the [CONDITION(S)] center but continued to allow the transportation of Resident 1 without a staff accompanying the resident for at least three additional days. Facility did not report to the necessary agencies and did not conduct a thorough investigation of the incident. This deficient practice resulted in the resident being subject to further mistreatment by the transportation driver using restraints to control Resident 1's behavior. […]

• Actual harm, isolatedF604Feb 7, 2022

  Based on interview and record review, facility failed to ensure one of three sampled residents (Resident 1) was free from unnecessary physical restraint. The facility sent Resident 1 unaccompanied to an outside treatment center three time a week using a transportation van. The transportation driver tied Resident 1 down to his wheelchair with a blanket during trip to control Resident 1's behavior of refusing to sit down. This deficient practice resulted in the resident being subject to further use of restraints to control Resident 1's behavior and causing the resident undetermined psychological trauma, mental anguish, and fear that a resident with impaired cognition may not express outward (reasonable person standard). On 10/ Resident 1 got an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF583Apr 23, 2026

  Based on observation, interview, and record review, the facility failed to ensure the confidential personal information of residents were protected by failing to ensure documents (diet typer report) containing protected information ([PHI]- any health information that can be used to identify specific individual which must remain confidential to prevent harmful consequences) were shredded prior to disposing in the waste container. This failure had the potential to violate 125 of 125 residents' rights for privacy and confidentiality of personal and medical records. […]

• No harm, potential for more than minimal, patternF689May 14, 2026

  Based on interview and record review, the facility's licensed nurses failed to conduct accurate fall risk assessments for two of four sampled residents (Resident 1 and Resident 2).These deficient practices had the potential to increase the residents' risk for falls and fall-related injuries. a. During a review of Resident 1's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated that the facility originally admitted Resident 1 on 1/27/2025 and readmitted on [DATE] with diagnoses that included left femur (thigh bone) fracture (broken bone), cerebral infarction (stroke, loss of blood flow to a part of the brain resulting in damage to brain tissue), contractures (stiffening/shortening at any joint, that reduces the… […]

• No harm, potential for more than minimal, patternF656Apr 23, 2026

  Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a document that outlines a resident's healthcare needs, goals, and the interventions planned to achieve those goals) by failing to:1. Develop a care plan that address monitoring of resident's behavior for three (Resident 1, Resident 8, Resident 14) of four sampled residents on physical restraints (any physical device attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of normal access to one's body) when the restraints were removed in accordance with the physician's order (called holidays). […]