National City Post Acute

In the surveyor’s words

From the most serious findings on record at National City Post Acute, in the surveyor’s own words.

• Actual harm, isolatedF689Aug 22, 2024

  Based on observation, interview, and record review, the facility staff failed to safely transfer one of five residents reviewed for pain (Resident 51) from the bed to the wheelchair, using a gait belt. As a result, Resident 51 sustained a fracture to the left humerus (shoulder). In addition, Resident 51's fistula (a site used for dialysis[a treatment to remove waste products from the blood]) was unusable, requiring Resident 51 to be hospitalized for the placement of a new dialysis access site. […]

• Actual harm, isolatedF689Sep 22, 2022

  Based on observation, interview and record review, for one of one resident reviewed for falls (Resident 25), the facility failed to ensure: 1. Adequate supervision and close monitoring were provided; and 2. Effectiveness of interventions were evaluated, and new interventions were implemented to address resident's behavior of getting up unassisted and prevent further falls. These failures resulted to Resident 25 to have five repeated falls in 2022 while at the facility. The resident's 5th incident of fall on September 20, 2022, resulted in Resident 25 sustaining left [CONDITION(S)] (broken bones), and was transferred out to acute hospital for further evaluation and surgery. […]

• No harm, potential for more than minimal, patternF578Dec 19, 2025

  Based on interview and record review, the facility failed to ensure documentation of written information regarding formulating an advanced directive and the right to accept or refuse medical treatment was provided to 9 of 10 sampled residents (6, 9, 25, 33, 34, 60, 62, 78 and 89). This failure had the result for residents to not have the opportunity to express wishes for care if capacity for decision making was lost and the right to accept or refuse treatment.FindingsOn 12/18/25 a review of Resident 6's clinical record was conducted. Resident 6 was admitted to the facility on [DATE] per the facility's admission Record. The facility did not have documentation that information regarding an Advance Directive was provided to Resident 6 or Resident 6's representative. […]

• No harm, potential for more than minimal, patternF584Dec 19, 2025

  Based on observation, interview, and record review, the facility failed to ensure a clean and homelike environment was provided for eight residents (51, 53, 92, 45,100, 95, 34, 31).This deficient practice had the potential to reduce comfort, feelings of security, and well-being for the residents. Findings: A review of Resident 51's admission Record indicated the resident was admitted to the facility on [DATE]. A review of Resident 53's admission Record indicated the resident was admitted to the facility on [DATE]. A review of Resident 92's admission Record indicated the resident was admitted to the facility on [DATE]. A review of Resident 45's admission Record indicated the resident was admitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, patternF656Dec 19, 2025

  Based on observation, interview, and record review, the facility failed to develop and implement resident-centered written care plans for 4 of 19 residents (92, 5, 95, and 60) when:1. Resident 92 kept perishable food routinely at her bedside and a care plan was not developed to address the behavior.2. Resident 95's severe weight loss was not care planned timely.3. Resident 5's care plan was not implemented when the resident's heel protector (device used to prevent pressure ulcer development) was not applied.4. Resident 60's left upper arm edema (fluid retention/swelling) was not care planned.As a result of these deficient practices, residents were at risk for not receiving care and treatment. Cross reference F686 and F580.Findings: 1. […]