California Nursing & Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, patternF692Mar 3, 2025

  Based on observation, interview, and record review, the facility failed to implement a comprehensive systematic approach to ensure effective monitoring to maintain acceptable parameters of nutritional status for 5 of 5 sampled Residents (23, 43, 51, 58, and 673) when: 1. Resident 23 experienced a severe unplanned weight loss of 16 lbs. (pounds- a measurement of weight), 8.04% from the weights obtained on 11/5/24 to 2/26/25. Weights were obtained but a weight loss change of condition was not completed, the resident was not placed on weekly weights, the Registered Dietitian (RD) did not reassess the resident to determine appropriate interventions, weight loss was not communicated to the Physician, the IDT (IDT- an interdisciplinary team comprised of professionals from various disciplines who… […]

• Immediate jeopardy, isolatedF689Nov 19, 2024

  Based on observation, interview, and record review, the facility failed to ensure the facility's policy and procedures were followed, for two of three sampled residents, Residents 1 and 2, who were identified as at risk for elopement (when a resident leaves a healthcare facility without permission or when they are unable to make safe decisions on their own), when: 1. The facility did not provide supervision for Resident 1 who had multiple prior attempts to elope; and 2. The facility did not ensure there was a system in place to monitor placement and functionality of the WanderGuard (bracelet worn by the resident that triggers alarms on doors to alert staff if a resident leaves a safe area) when Resident 2 was observed not wearing a WanderGuard bracelet as ordered by the physician. […]

• Actual harm, isolatedF686Jul 9, 2026

  Based on observation, interview, and record review, the facility failed to ensure wound treatments ordered by a wound consultant were implemented in a timely manner for five of six residents reviewed for pressure injuries (PI - bed sore), Residents 1, 2, 3, 4, and 5.This failure resulted in the delay of the appropriate treatment as ordered by the wound consultant and contributed to the worsening of Residents 1 and 2's PI. In addition, this failure had the potential to contribute to the worsening of Residents 3, 4 and 5's PI.Findings:1.A review of Resident 1's admission Record indicated that the resident was admitted to the facility on [DATE], with diagnoses which included fracture (break in the bone) of the right tibia. […]

• No harm, potential for more than minimal, widespreadF812May 7, 2026

  Based on observation, interview, and record review, the facility failed to maintain the kitchen environment in a clean and sanitary condition when:1. The kitchen sink and underneath the preparation counter were found to have black residue, dark build up, and areas of flaking and rusty-brown discoloration.2. The underside and bottom portion of the kitchen sink were coated with stains and spots of scattered yellow and brown food debris. 3. The kitchen sink's white funnel-shaped drainpipe contained debris, rust, and old food residue. These failures had the potential to expose residents to contaminants and increased the risk of food-borne illnesses.Findings:1. […]

• No harm, potential for more than minimal, widespreadF851May 7, 2026

  Based on interview and record review, the facility failed to ensure its Payroll Based Journal (a mandated reporting system used by the Centers for Medicare & Medicaid Services (CMS) to collect auditable, employee-level staffing data from long-term care facilities) was submitted for the first fiscal year quarter.This deficient practice resulted in the facility's failure to provide required information regarding staffing levels necessary to ensure the provision of safe and comprehensive care for all residents in accordance with federal regulations.Findings:During a review of the facility's PBJ Staffing Data Report for Fiscal Year Quarter 1, dated 4/26/26, the PBJ report indicated the facility failed to submit data for the fiscal year (FY) quarter 1 2026 (October 1-December 31). […]