Health Care CTR at the Forum at Rancho San Antonio

In the surveyor’s words

From the most serious findings on record at Health Care CTR at the Forum at Rancho San Antonio, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Jan 30, 2026

  Based on observation, interview, and policy review, the facility failed to ensure food was stored and equipment was maintained in accordance with professional standards for food safety when undated food items, food past their discard by date, uncovered food, rotten vegetables, and old, chipped, worn-out equipment were found in the kitchen.These failures had the potential to cause the growth of micro-organisms which could cause foodborne illness and cross-contaminated food for the 44 residents eating at the facility, with one resident on tube feeding and still eating lunch.Findings:On 1/26/26, at 9:10 a.m., during an observation of the kitchen with executive chef E (EC E), the following were observed: a. One pure [NAME] maple syrup with discard by dated 1/23/26b. […]

• No harm, potential for more than minimal, patternF578Jan 30, 2026

  Based on interview and record review, the facility failed to ensure three of 14 residents (Resident 51, 17 and 59) had been informed about having an advance directive (AD, legal form directing their wishes about their healthcare, whether from them or a named individual on their behalf), when no documentation was found about AD and the Physician Orders for Life-Sustaining Treatment (POLST, a legal document stating the kind of medical treatment residents want toward the end of their lives) were not completed and not readily available in the event of a medical emergency.This failure had the potential to result in inability to make medical decisions and could lead to the delivery of unnecessary or inappropriate medical services.Findings:Review of Resident 51's admission Record indicated he was… […]

• No harm, potential for more than minimal, patternF605Jan 30, 2026

  Based on interview and record review, the facility failed to ensure 3 out of 5 sampled residents (Residents 1, 35, and 51) were free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behavior) when:1. Resident 1 received trazodone (an antidepressant) for insomnia without side effect monitoring and without adequate monitoring when staff did not monitor the quantity (hours) of sleep to evaluate whether the medication was effective for her insomnia.2. Resident 35 received trazodone for insomnia without adequate monitoring for hours of sleep.3. […]

• No harm, potential for more than minimal, patternF656Jan 30, 2026

  Based on interview and record review, the facility failed to ensure the comprehensive care plan with measurable objectives, goals, and interventions, was developed and implemented for 4 out of 14 sampled residents (Residents 1, 3, 38, and 52), when:1. Resident 1 did not have care plans for migraine and insomnia;2. Resident 38 did not have a care plan related to use of apixaban (Eliquis, an anticoagulant - or blood thinner- to prevent blood clots) and osteoporosis (a bone disease causing weak, brittle bones due to decreased bone mass). 3. Resident 3 did not have a care plan developed for pressure ulcer; and4. […]

• No harm, potential for more than minimal, patternF697Jan 30, 2026

  Based on interview and record review, the facility failed to manage pain for one of 5 residents (29) when license nurses did not administer pain medication to Resident 29 according to the pain level ordered by the physician. This failure had the potential for the residents to experience avoidable pain and could negatively affect their quality of life.Findings:Review of Resident 29's admission Record indicated he was admitted to the facility on [DATE] with pain in left knee and gout (characterized by sudden, severe attacks of pain, swelling, redness and tenderness in one or more joints, most often in the big toe) diagnoses.Review of Resident 29's physician order, dated 2/11/25, indicated he had an order for acetaminophen (a drug that reduces pain and fever) 325 milligrams (mg, a metric unit… […]