HEALTH CARE CTR AT THE FORUM AT RANCHO SAN ANTONIO
Non profit - Other
48 Beds
Independent
Data: November 2025
Trust Grade
80/100
#94 of 1155 in CA
Last Inspection: July 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
The Health Care Center at the Forum at Rancho San Antonio has a Trust Grade of B+, which means it is above average and recommended for families considering care. It ranks #94 out of 1,155 facilities in California, placing it in the top half, and #4 out of 50 in Santa Clara County, indicating only three local options are better. However, the facility's trend is worsening, as the number of issues reported increased from 5 in 2023 to 14 in 2024. Staffing is rated 5 out of 5 stars, with a turnover rate of 40%, which is average and suggests some stability among staff who know the residents well. Although there have been no fines, the facility has faced concerns such as failing to properly document residents' advance directive statuses, storing expired medications, and not adhering to food safety standards, which could potentially harm residents. Overall, while the facility has strengths in staffing and care ratings, it needs to address these significant concerns to improve resident safety.
- Trust Score
- B+
- In California
- #94/1155
- Safety Record
- Low Risk
- Inspections
- Getting Worse
- Staff Stability ○ Average
- 40% turnover. Near California's 48% average. Typical for the industry.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most California facilities.
- Skilled Nurses ✓ Good
- Each resident gets 66 minutes of Registered Nurse (RN) attention daily — more than 97% of California nursing homes. RNs are the most trained staff who catch health problems before they become serious.
- Violations ⚠ Watch
- 22 deficiencies on record. Higher than average. Multiple issues found across inspections.
80/100
Top 8%
No red flags
5 → 14 violations
★★★★★
5.0
Overall Rating
★★★★★
5.0
Staff Levels
★★★★★
5.0
Care Quality
★★★★☆
4.0
Inspection Score
↔
Stable
2023: 5 issues
2024: 14 issues
The Good
-
5-Star Staffing Rating · Excellent nurse staffing levels
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (40%)
8 points below California average of 48%
Facility shows strength in staffing levels, quality measures, fire safety.
The Bad
Staff Turnover: 40%
Near California avg (46%)
Typical for the industry
The Ugly 22 deficiencies on record
Sept 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure care and services were provided in accordance with professio...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for one of three sample residents (Resident 1) when:
1. The facility scheduled a change in medication administration time to start on 7/17/24 when it should have started on 7/18/24; and,
2. A medication was documented as administered when it should have been documented as refused.
These failures had the potential to compromise the resident's health and well-being.
Findings:
1. Review of Resident 1's medical record indicated she was admitted on [DATE] and had diagnoses including hypertension (high blood pressure).
Review of Resident 1's Order Summary Report indicated she had a physician's order, dated 7/8/24, for lisinopril (medication used to lower blood pressure) 5 milligrams (mg, unit of dose measurement) three tablets (total of 15 mg) by mouth one time a day for hypertension. From 7/9/24 to 7/17/24, this medication was scheduled to be administered at 9:00 a.m.
Review of Resident 1's medication administration record (MAR) indicated on 7/17/24, Resident 1 received her daily dose of lisinopril as ordered at 9:00 a.m.
Review of Resident 1's Progress Notes, dated 7/17/24, indicated Resident 1's physician saw her at 11:00 a.m. and gave a new order to administer lisinopril in the evening. The Progress Notes indicated, Order noted and carried out.
Review of Resident 1's Order Details, dated 7/17/24, indicated a staff member carried out a new order for lisinopril 5 mg three tablets by mouth every day for hypertension. The staff member scheduled an administration time of 5:00 p.m., with a start date of 7/17/24.
During an interview and concurrent record review with the director of nursing (DON) on 9/6/24, at 10:44 a.m., the DON reviewed Resident 1's medical record and confirmed the new evening administration time for Resident 1's daily dose of lisinopril was scheduled to start at 5:00 p.m. on 7/17/24. The DON acknowledged that per documentation, Resident 1 had already received her daily dose of lisinopril at 9:00 a.m. that day. The DON confirmed Resident 1's new administration time for lisinopril should have been scheduled to start the following day, 7/18/24.
During an interview with registered nurse A (RN A) on 9/6/24, at 2:50 p.m., RN A confirmed she was the one who carried out the physician's order to start administering Resident 1's lisinopril in the evening. RN A confirmed that when she carried out the order on 7/17/24, she had already administered Resident 1's daily dose of lisinopril at 9:00 a.m. that day. RN A confirmed the new evening administration time for Resident 1's daily dose of lisinopril was supposed to be scheduled to start the following day, 7/18/24. RN A stated, That was my mistake.
2. Review of Resident 1's Order Summary Report indicated she had a physician's order, dated 7/8/24, for lisinopril 5 mg three tablets by mouth one time a day for hypertension. From 7/9/24 to 7/17/24, this medication was scheduled to be administered at 9:00 a.m.
Review of Resident 1's MAR indicated on 7/17/24, Resident 1 received her daily dose of lisinopril as ordered at 9:00 a.m.
Review of Resident 1's Progress Notes, dated 7/17/24, indicated Resident 1's physician saw her at 11:00 a.m. and gave a new order to administer lisinopril in the evening. The Progress Notes indicated, Order noted and carried out.
Review of Resident 1's Order Details, dated 7/17/24, indicated a staff member carried out a new order for lisinopril 5 mg three tablets by mouth every day for hypertension. The staff member scheduled an administration time of 5:00 p.m., with a start date of 7/17/24.
Further review of Resident 1's MAR was conducted. The documentation indicated Resident 1 also received lisinopril 5 mg three tablets by mouth at 5:00 p.m. on 7/17/24.
During an interview and concurrent record review with the DON on 9/6/24, at 10:44 a.m., the DON reviewed Resident 1's MAR and confirmed the documentation indicated that on 7/17/24, Resident 1 received lisinopril 5 mg three tablets by mouth at 9:00 a.m. and 5:00 p.m.
During an interview with RN A on 9/6/24, at 2:50 p.m., RN A confirmed she administered lisinopril 5 mg three tablets by mouth to Resident 1 on 7/17/24 at 9:00 a.m. RN A explained later that day, Resident 1's physician gave an order to start administering lisinopril in the evening. RN A further explained when she entered the new order in the computer system, she mistakenly scheduled the evening lisinopril to start at 5:00 p.m. on 7/17/24 instead of the following day. RN A stated that on 7/17/24, the evening nurse tried to administer the 5:00 p.m. dose of lisinopril to Resident 1, but the resident refused it because she had already taken the medication at 9:00 a.m. that morning.
During a follow-up interview and concurrent record review with the DON on 9/6/24, at 2:52 p.m., the DON stated if Resident 1 refused to take lisinopril on 7/17/24 at 5:00 p.m., this should have been documented in the medical record. The DON reviewed Resident 1's medical record and confirmed there was no documentation that indicated Resident 1 refused lisinopril on 7/17/24 at 5:00 p.m.
The facility's policy titled Administering Medications, dated 2001, indicated if a medication is withheld or refused, the individual administering the medication shall initial and circle the MAR space provided for that medication and dose.
The facility's policy titled Documentation of Medication Administration, revised 11/2022, indicated to document the reasons why a medication was withheld, not administered, or refused.
Jul 2024
13 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure to treat with dignity and privacy for 1 of 2 sampled Resident (Resident 332) when:
1. Resident 332's foley catheter (F...
Read full inspector narrative →
Based on observation, interview and record review, the facility failed to ensure to treat with dignity and privacy for 1 of 2 sampled Resident (Resident 332) when:
1. Resident 332's foley catheter (F/C: a semi-flexible plastic tube, one end inserted into bladder [ a body organ that stores urine] and the other end attached to a bag that collects urine) drain bag (collects urine that drains through the F/C) was left uncovered.
These failure had the potential for adverse effects on the psychosocial well-being and health of Resident 332.
Findings:
1. Review of Resident 332's face sheet ((FS: a document that gives a resident's information at a quick glance) indicated Resident 332 was admitted to facility on 7/9/224. Review of Resident 332's admission diagnoses included fracture of superior rim of left pubis (broken bone in pelvis (basin shaped complex of bones that connects the trunk and legs of the body)].
Review of Resident 332's physician order dated 7/9/2024 indicated, Foley Catheter Fr.16 (F/C size) due to diagnosis ---change per MD (medical doctor) schedule and PRN (as needed) obstruction.
During an observation on 7/15/2024 at 9:27 a.m., noted Resident 332's F/C drain bag uncovered and secured in a wash basin (durable plastic container used for body wash for residents) on the floor next to Resident's 332's bed.
During an interview with license vocational nurse C (LVN C) on 7/15/2024 at 9:37 a.m., LVN C confirmed Resident 332's F/C's drain bag was not covered. LVN C Stated F/C drain bag should be covered with a privacy bag. LVN C also stated nursing staff should have covered F/C drain bag with a privacy bag to provide privacy and dignity for Resident 332.
During an interview with facility's infection preventionist (IP) on 7/19/2024 at 8:37 a.m., IP stated nursing staff should have covered Resident 332's F/C drain bag with privacy bag to maintain privacy and dignity for Resident 332.
During an interview with facility's director of nursing (DON) on 7/19/2024 at 10:08 a.m., DON stated nursing staff should have used privacy bag to cover F/C drain bag for resident's privacy and dignity.
During a review of facility's policy and procedure (P&P) titled, Dignity, revised February 2021, the P&P indicated, Residents are treated with dignity and respect at all times. Staff are expected to promote dignity and assist residents; for example: a. helping the resident to keep urinary catheter bags covered;
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to give notice of ending of Medicare Part A stay or therapies under Part B within a timely manner to one of three randomly selected residents ...
Read full inspector narrative →
Based on interview and record review, the facility failed to give notice of ending of Medicare Part A stay or therapies under Part B within a timely manner to one of three randomly selected residents (Resident 26). This failure had the potential for Resident 26 not being able to appeal for continued payment by Medicare.
Findings:
During a review of Resident 26's SNF (Skilled Nursing Facility) Beneficiary Notification Review (SNF BNR), dated 5/23/2024, the SNF BNR indicated Resident 26's Medicare part A Skilled Services last day of coverage was 5/23/2024. The date Resident 26's SNF BNR was signed was 5/23/2024.
During an interview on 7/18/24 at 10:57 a.m. with the administrator (ADM), ADM stated Resident 26's last day covered was 5/23/24, and the SNF BNR notice was given on 5/23/24. ADM stated Resident 26 should have had 48 hours between giving notice and their last day of coverage. It was not done in this situation.
During a review of the facility's policy and procedure titled Health Information Record Manual: Chapter VII 7020 Medicare Notice of Medicare Non-Coverage/Advance Beneficiary Notice, revised 11/21/2018, indicated 1) The facility will give an advance, completed copy of the Notice of Medicare Non-Coverage (NOMNC) to enrollees receiving skilled nursing no later than two days before the termination of services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, an assessment tool) was accurate ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, an assessment tool) was accurate for one of 14 sampled residents (Resident 19). For Resident 19, the assessment of his alarm device was inaccurate and the MDS did not reflect the presence of a wanderguard (a device that activates an alarm when a resident attempts to leave a safe area.)
Failure to accurately assess Resident 19's use of a wanderguard had the potential to compromise the facility's ability to develop and implement resident-centered care plans and interventions.
Findings:
Review of Resident 19's clinical record indicated he had diagnoses including dementia (decline in mental capacity affecting daily function), history of falling, and the need for assistance with personal care.
Review of Resident 19's MDS, dated [DATE], indicated he had a brief interview for mental status (BIMS, an assessment to test a person's cognition level) score of 3 [a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact].
Review of Resident 19's clinical notes, dated 8/3/23, indicated an attempted elopement (leaving unsupervised and undetected) occurred by Resident 19. The clinical notes indicated an ordered was obtained from Resident 19's physician to apply a wanderguard, and Resident 19's family was notified and gave consent for the wanderguard to be applied to Resident 19's left wrist.
Review of Resident 19's MDS, dated [DATE], indicated Section P0200 assessed alarms. Section P0200 identified an alarm as any physical or electronic device that monitors resident movement and alerts staff when movement is detected. Section P0200 identified Coding: 0. not used, 1. Used less than daily, and 2. Used daily. The MDS assessment performed on 3/8/24 indicated Resident 19's Wander/elopement alarm was coded as 0, indicating wanderguard not used.
During an interview and concurrent record review with the director of nursing (DON) on 7/17/24 at 10:43 a.m., she confirmed Resident 19 was wearing a wanderguard and a physician's order and consent had been obtained on 8/3/23. The DON reviewed the MDS, dated [DATE] and confirmed Section P0200 indicated that wander/elopement alarm was not used. The DON stated the MDS is inaccurate and should reflect the use of Resident 19's wanderguard. She further stated the staff member who authored the 3/8/23 MDS was no longer employed by the facility and was not available for an interview.
According to the 2023 Resident Assessment Instrument Version 3.0 Manual (RAI Manual, MDS coding instructions), Alarms are defined as Any physical or electronic device that monitors resident movement and alerts the staff when movement occurs. Wander/elopement alarm includes devices such as bracelets, pins/buttons worn on the resident's clothing, sensors in shoes, or building/unit exit sensors worn by/attached to the resident that activate an alarm and/or alert the staff when the resident nears or exits a specific area or the building. The RAI Manual further indicates coding instructions to Record the frequency that the resident was restrained by any of the listed devices or an alarm was used at any time during the day or night.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to implement their elopement risk care plan (a written doc...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to implement their elopement risk care plan (a written document which communicates and directs the care and services, including goals and interventions required to meet a resident's individualized need) for one of 14 sampled residents (Resident 19). This failure had the potential for Resident 19's attempts at elopement to go undetected and jeopardize Resident 19's safety.
Findings:
Review of Resident 19's clinical record indicated he had diagnoses including dementia (decline in mental capacity affecting daily function), history of falling, and the need for assistance with personal care.
Review of Resident 19's MDS, dated [DATE], indicated he had a brief interview for mental status (BIMS) score of 3 (a score of 0 to 7 indicates severe cognitive impairment).
Review of Resident 19's clinical notes, dated 8/3/23, indicated an attempted elopement (leaving unsupervised and undetected) occurred by Resident 19. The clinical notes indicated an ordered was obtained from Resident 19's physician to apply a wanderguard (a device that activates an alarm when a resident attempts to leave a safe area.), which was applied to Resident 19's left wrist.
During an interview with the director of nursing (DON) on 7/17/24 at 10:43 a.m., she confirmed Resident 19 has a wanderguard applied to his left wrist and she stated he has frequent behaviors of wandering and looking for his wife. During a concurrent record review, the DON confirmed Resident 19 had the wanderguard applied on 8/3/23 after an episode of attempted elopement. When asked if staff is monitoring Resident 19's wandering and exit seeking behaviors, the DON stated licensed nurses would document wandering episodes every shift on Resident 19's treatment record (TAR). During a concurrent record review with the DON, she reviewed Resident 19's TAR and confirmed there was no evidence that licensed nurses were monitoring Resident 19's wandering behaviors or exit seeking episodes.
Review of Resident 19's care plan, dated 1/13/24, indicated Resident 19 was an elopement risk and had impaired safety awareness. The interventions to address the elopement risk problem included: to identify pattern of wandering; monitor location throughout the shift; and to document wandering behavior. During an interview and concurrent record review with the director of nursing (DON) on 7/17/24 at 10:43 a.m., Resident 19's care plan was reviewed. The DON confirmed the interventions to monitor Resident 19's wandering behaviors were not implemented. The DON stated the wandering behaviors and exit seeking episodes need to be monitored.
Review of the facility's undated policy titled Wandering and Elopements, indicated the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm. The policy further indicated If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain resident's safety.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to follow their policy and procedure (P&P) for medication...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to follow their policy and procedure (P&P) for medication order for one of five sampled resident (Resident 340) when;
1. Resident 340 received medication pantoprazole sodium delayed release (used to reduce amount of acid in stomach to release the active ingredient (s) later after taking it) after breakfast.
This failure had the potential to affect the health and well-being of Resident 340.
Findings:
Review of Resident 340 face sheet (a document that gives a resident's information at a quick glance) indicated Resident 340 was admitted to the facility on [DATE].
Review of Resident 340's physician orders dated 7/6/2024 indicated, pantoprazole Sodium Oral Tablet Delayed Release 40 mg (pantoprazole Sodium) Give 1 tablet by mouth in the morning for every morning before breakfast.
Review of Resident 340's minimum data set (MDS: clinical assessment tool) assessment dated [DATE] indicated Resident 340 brief interview for mental status (BIMS) score of 14/15 (0-7: severely impaired cognition, 8-12: moderately impaired cognition, 13-15: intact cognition).
During a medication administration observation on 7/17/2024 at 8:09 a.m., with license vocational nurse A (LVN A), observed LVN A administered medication pantoprazole sodium delayed release 40 mg to Resident 340 along with other ordered medications for Resident 340.
During an interview with Resident 340 on 7/17/2024 at 11:10 a.m., Resident 340 confirmed LVN A gave all medications after Resident 340 ate breakfast, not before breakfast.
During an interview with facility's director of nursing (DON) on 7/19/2024 at 9:58 a.m., DON stated license nurse should have followed MD (medical doctor)'s order to give medication before breakfast not after Resident 340 ate breakfast on 7/17/2024.
Review of facility's P&P titled, Medication and Treatment orders, revision dated July 2016, the P&P indicated, Nursing staff will review the overall situation for the resident to ensure that any related issues are addressed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow physician's orders to administer oxygen (O2: co...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow physician's orders to administer oxygen (O2: colorless, odorless, and tasteless gas supports life) for 1 of 2 sampled resident (Resident 24). This failure had the potential to compromise Resident 24's health, and well-being.
Findings:
Review of Resident 24's face sheet (a document that gives a resident's information at a quick glance) indicated Resident 24 was admitted to the facility on [DATE]. Review of Resident's admission diagnoses including transient ischemic attack (a condition caused by brief blockage of blood flow to the brain), thrombocytosis [blood has a higher-than-normal platelet (particles in blood that help the blood to become gel to manage bleeding) count], and atherosclerotic heart disease (a sticky substance called plaque builds up inside arteries [blood vessels carry blood from heart to body organs]).
Review of Resident 24's physician orders for dated 6/23/2024 indicated, Oxygen: Administer 5 LPM (liters per minute: oxygen measured in liters per minute) via Nasal Cannula (NC: a medical device to provide supplemental oxygen to residents) continuously. May increase up to 8 LPM of O2 saturation (blood oxygen level) below 90 or increased SOB (shortnesss of breath, difficulty breathing).
During an observation on 7/15/2024 at 10:53 a.m., noted Resident 24's room air concentrator (RAC: a medical device that take in air from the room and filter out nitrogen to provides higher amounts of oxygen) was set at 4LPM oxygen to deliver via NC for Resident 24.
During an interview with license vocational nurse A (LVN A) on 7/15/2024 at 11:03 a.m., LVN A confirmed Resident 24's RAC oxygen rate indicator was set at 4 LPM.
During a second observation on 7/17/2024 at 9:15 a.m., noted Resident 24's RAC oxygen rate indicator was set at 4LPM oxygen to deliver via NC for Resident 24.
During another concurrent observation, review of Resident 24's physician orders for oxygen and interview with registered nurse B (RN B) on 7/17/2024 at 1:30 p.m., RN B confirmed Resident 24's RAC oxygen rate indicator was set at 4 LPM. RN B also confirmed Resident 24 had an order for oxygen 5 LPM. RN B adjusted RAC's oxygen rate to 5 LPM and stated staff should have verified and followed physician order for oxygen rate for Resident 24. RN B also stated staff should have set oxygen rate at 5 LPM, not at 4 LPM for Resident 24 as ordered.
During an interview with director of nursing (DON) on 7/19/2024 at 9:50 a.m., DON stated staff should have followed MD (medical doctor) 's order to set oxygen rate at 5 LPM for Resident 24.
Review of facility's policy and procedure (P&P) titled, Oxygen Administration, revised undated, the P&P indicated, Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to determine if bed rails were appropriate for two of 39 resident (Residents 17 and 81) prior to installing them. This failure had the potenti...
Read full inspector narrative →
Based on interview and record review, the facility failed to determine if bed rails were appropriate for two of 39 resident (Residents 17 and 81) prior to installing them. This failure had the potential of the residents being harmed from improper bed rail use.
Findings:
During a review of the medical record for Resident 17, a bed rail assessment was not located. Nor was the alternatives used, a physician order, or a care plan for their use, prior to installation.
During a review of the medical record for Resident 81, neither a bed rail assessment, the alternatives used, a physician order, or a care plan for their use, prior to installation, were not located.
During an interview on 7/19/24 at 2:28 p.m. with the director of nursing (DON), the DON stated Residents 17 and 81 do not have a physician order, assessment, alternatives attempted documented, nor a care plan.
During a review of the facility's policy and procedure titled Bed Safety and Bed Rails, revised 08/2022, indicated under the sub-heading Use of Bed Rails .3. The use of bed rails or side rails .is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent.
4. Prior to the installation or use of a side or bed rail, alternatives to the use of side or bed rails are attempted 5. If attempted alternatives do not adequately meet the resident's needs the resident may be evaluated for the use of bed rails. This interdisciplinary evaluation includes: .d. consultation with the attending physician.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Information
(Tag F0732)
Could have caused harm · This affected 1 resident
Based on observation and interview, the facility failed to post the nurse staffing hours in a prominent place. This failure did not follow the federal regulation of posting them in a prominent place r...
Read full inspector narrative →
Based on observation and interview, the facility failed to post the nurse staffing hours in a prominent place. This failure did not follow the federal regulation of posting them in a prominent place readily accessible to residents and visitors.
Findings:
During an observation of the nurses station during the time of the survey, the posting for the licensed and unlicensed nursing staff total number and actual hours worked was not located.
During an interview on 7/19/24 at 9:29 a.m. with the administrator (ADM), the ADM stated the nursing numbers are posted in the hallway that is blocked off right now because of constriction and painting. After the surveyor brought it to the ADM's attention, the ADM stated let me get those moved.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure 1 of 2 sampled resident (Resident 339) was free from unnece...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure 1 of 2 sampled resident (Resident 339) was free from unnecessary psychotropic medication (drug that affects brain activities associated with mental processes and behaviors) when;
1. No target behavior monitoring for use of medication quetiapine (antipsychotic medication used to treat certain mental/mood disorders);
2. No non-pharmacological (any type of healthcare interventions without use of medications) approaches to minimize the need to use for medication quetiapine;
3. Pharmacy consultant (expertise in managing medications and providing clinical guidance on safe and appropriate medication use for residents)'s recommendations for quetiapine had not been followed up and;
4. MD (medical doctor)'s response for pharmacy recommendations had not been followed up.
These failures resulted in inadequate monitoring and unnecessary medication for Resident 339, which potentially placed the resident at risk for experiencing harmful adverse effects from the antipsychotic medication.
Findings:
Review of Resident 339's face sheet (FS: a document that gives a resident's information at a quick glance) indicated Resident 339 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease (a progressive brain disorder that affects memory, thinking, and behavior).
Review of Resident 339's physician's orders indicated, Quetiapine Fumarate Oral Tablet 25 MG (milligram, unit of measure) (Quetiapine Fumarate) Give 1 tablet by mouth in the afternoon for Alzheimer's with behavioral disorder as m/b (manifested by), dated 6/28/2024.
1. Review of clinical documentation for Resident 339 indicated there was no documented evidence for target behavior monitoring for use of Quetiapine for Resident 339.
2. Review of clinical documentation for Resident 339 indicated there was no documented evidence of facility used non-pharmacological approaches to minimize the need for use of Quetiapine for Resident 339.
3. Review of pharmacy consultant's recommendations for medication Quetiapine for Resident 339 dated 7/1/2024 indicated, Please identify target behaviors. If resident's behaviors have stabilized, please notify MD for gradual dose reduction (GDR: attempts of lowest effective dose and discontinuation of medication) of Quetiapine Fumarate to 12.5 mg qd (one time every day) x 3 days, then DC (discontinue).
Further review of pharmacy consultant's report indicated for Physician's Response indicated Resident 339's MD approved above pharmacy consultant's recommendations for Quetiapine on 7/10/2024.
4. Review of Resident 339's clinical documentation indicated there was no documented evidence for pharmacy consultant's and MD's response for Quetiapine been followed up for Resident 339.
During an interview with facility's director of nursing (DON) on 7/19/2024 at 10:11 a.m., DON acknowledged there were no monitoring for target behaviors, providing non-pharmacological approaches, pharmacy consultant's recommendations and MD's response for Quetiapine had not been followed up for Resident 339.
DON stated nursing staff should have monitored target behaviors and provided non-pharmacological approaches when Resident 339 received antipsychotic medication quetiapine. DON further stated nursing staff should have been followed up as soon as possible when received MD's response for pharmacy consultant's recommendations for Quetiapine for Resident 339.
Review of facility's policy and procedure P&P titled, Psychotropic Medication Use, revised July 2022, the P&P indicated, Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications:
a.
Anti-psychotics
d. adequate monitoring for efficacy (effectiveness)
8. Consideration of the use of any psychotropic medication is based on comprehensive review of the resident. This includes evaluation of the resident's signs and symptoms in order to identify underlying causes.
10. Non-pharmacological approaches are used (unless contraindicated) to minimize the need for medications, permit the lowest possible dose, and follow for discontinuation of medications when possible.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to ensure 5 of 11 resident (Residents 3, 13, 24, 334, and 336) had:
1. documentation of reviewing advance directive status, when there was no...
Read full inspector narrative →
Based on interview and record review, the facility failed to ensure 5 of 11 resident (Residents 3, 13, 24, 334, and 336) had:
1. documentation of reviewing advance directive status, when there was no documentation of a staff member discussing the status with four of the residents or residents' representative, or
2. the POLST (Physician Orders for Life Sustaining Treatment) for three residents, were not filled in accurately, when Section D had no check marks for the advance directive status.
Findings:
1. Review of Resident 13's face sheet (FS: a document that gives a resident's information at a quick glance) indicated Resident 13 was admitted to facility on 3/4/2019.
Review of Resident 13's POLST form dated 11/1/2022 indicated, section D for advance directive (AD)'s all three options were left blank, not completed.
Review of Resident 13's clinical record indicated there was no document for advance directive.
Further review of Resident 13's clinical record indicated there was no documented evidence for facility discussed for AD or offered help to execute AD or requested copy of executed of AD for Resident 13.
Review of Resident 24 's FS indicated Resident 24 was admitted to facility on 10/1/2023.
Review of Resident 24's POLST form dated 4/25/2024 indicated, section D for AD documented as Advance Directive not available.
Review of Resident 24's clinical record indicated there was no documented evidence for facility discussed for AD or offered or assisted to execute AD for Resident 24.
Review of Resident 334's FS indicated Resident 334 was admitted to facility on 6/26/2024.
Review of Resident 334's POLST form date prepared on 6/26/2024 indicated, section D for AD documented as No Advance Directive.
Review of Resident 334's clinical record indicated there was no documented evidence of facility discussed for AD or offered or assisted to execute AD for Resident 334.
Review of Resident 336's face sheet indicated Resident 336 was admitted to facility on 3/27/2018.
Review of Resident 336's POLST form date prepared on 5/22/2024 indicated, section D for AD's all three options were left blank, not completed.
During an interview with facility's social worker (SW) on 7/18/2024 at 12:55 p.m., SW confirmed there was no documentation to provide evidence for facility requested copy of executed AD or discussed for AD or offered or assisted to execute AD for Residents 13, 24, and 334. SW stated social service staff should have obtained copy of executed AD or discussed for AD or offered and assisted to execute AD for Residents 13, 24, and 334.
During an interview with facility's director of nursing (DON) on 7/19/2024 at 10:593 a.m., DON confirmed above Residents 13, 24, 334 and 336 for AD and POLST form findings. DON stated social service staff should have discussed or offered or assisted to execute AD or requested for a copy of executed AD and documented in the resident's medical record for Residents 13, 24, and 334. DON also stated nursing staff should have completed all sections of POLST form for Residents 13 and 336.
2. Resident 3 was admitted with diagnoses which included Alzheimer's Disease (involves parts of the brain that control thought, memory, and language), moderate persistent asthma, need for assistance with personal care, and nutritional deficiency.
During a review of the POLST in Resident 3's medical record, Section D, titled Information and Signatures, indicated their were no checked boxes for Advance Directive date_______ available and reviewed, Advance Directive not available, nor No Advance Directive. One of these boxes should have been checked to inform of the status of Resident 3's Advance Directive.
During an interview with an admissions staff member (AD) on 7/18/24 at 10:19 a.m., AD stated Resident 3's Advance Directive is not in the system. None of the check boxes in section D of Resident 3's POLST are checked.
Review of facility's P&P titled, Advance Directive, revised, undated, the P&P indicated, Determining Existence of Advance Directive
1 Prior to or upon admission of a resident, the social service director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives.
2. The resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so.
4. Written information includes a description of the facilities policies to implement advance directives and applicable state law.
If the Resident Does not have an Advance Directive:
1 b. Nursing staff will document in the medical record the offer to assist and the residents decision to accept or decline assistance.
2. Information about whether or not the resident has executed an advance directive is displayed prominently in the medical record in a section of the record that is retrievable by any staff.
If the Resident Has an Advance Directive:
1. If the resident or the resident's representative has executed one or more advance directive(s), or executes one upon admission, copies of these documents are obtained and maintained in the same section of the resident's medical record and are readily retrievable by any staff.
Review of State of California law for POLST form indicated Completing a POLST form is voluntary. California law requires that a POLST form be followed by healthcare providers and provides immunity to those who comply in good faith. Any incomplete section of POLST implies full treatment for that section. Refer to WWW.caPOLST.org.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure proper storage of medications in medication room when the following were found:
1. An expired over the counter (OTC: ...
Read full inspector narrative →
Based on observation, interview, and record review, the facility failed to ensure proper storage of medications in medication room when the following were found:
1. An expired over the counter (OTC: medications can buy without written by medical doctor) medications;
2. An expired suppositories (supp: solid, small, and cone shaped medications that melts upon insertion into the body).
These failures had the potential for residents to receive medications with reduced efficacy (effectiveness).
Findings:
1. During an observation of facility's medication room (where facility stores medications) along with director of nursing (DON) on 7/18/2024 at 7:59 a.m., observed one container of psyllium powder (fiber supplement to help with digestive health and bowel regularity) expired on 6/2024. One bottle of geri-lanta (used to treat for stomach upset) expired on 5/2024, and one bottle of milk of magnesia (used to treat for stomach upset or indigestion [stomach discomfort after eating food]) expired on 6/2024. These expired medications were stored in OTC medication supply cabinet in medication room.
During interview with DON on 7/18/2024 at 8:10 a.m., DON confirmed above findings. DON stated license nursing staff should have verified expiration dates for OTC medications in the medication room every week. DON also stated license nursing staff should have removed expired OTC medications and disposed every week.
2. During an observation medication room along with DON on 7/18/2024 at 8:30 a.m., noted below medications stored in OTC medication supply cabinet:
a. Box of 12 prochlorperazine (brand name for compro: used to treat nausea and vomiting) 25 mg (milligram: a unit of measure) supp expired on 3/2023.
b. Count of three supp of acetaminophen (used to treat minor aches, pains, and fever) 650 mg expired on 7/13/2023, and another four supp expired on 3/6/2024.
c. Count of 4 bisacodyl (used to treat constipation [a problem with passing stool] 10 mg supp expired on 7/13/2024, and one another supp expired on 7/5/2024.
d. Count of 3 hydrocortisone (used to treat variety of skin conditions to reduce pain and swelling) 25 mg supp expired on 7/2023.
e. Box of benacalorie (brand name nutritional supplement to enhance more calories and protein sources) expired on 6/21/204.
During an interview with DON on 7/18/2024 at 8:43 a.m., DON confirmed above observations. DON stated license nursing staff should have verified expiration date for all OTC medications and nutritional supplements in the medication room once a week. DON also stated license staff should have removed expired medications, nutritional supplements and disposed every week.
During review of facility's policy and procedure (P&P) titled, Disposal/Destruction of Expired Of Discontinued Medications, revised February 2023, the P&P indicated, Facility should place all discontinued or outdated medications in a designated, secure location which is solely for discontinued medications or marked to identify the medications are discontinued and subject to destruction.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food safety when:
1. B...
Read full inspector narrative →
Based on observation, interview and record review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food safety when:
1. Bowls used for food preparation and food service were stacked and stored wet;
2. There were undated and outdated food items in the facility's kitchen freezer;
These failures had the potential to cause food contamination and food-borne illness to 38 of 39 residents who received their food from the kitchen.
Findings:
1. During an observation on 7/15/24 at 8:55 a.m., there were 3 large metal bowls and one small metal bowl observed to be stacked on a metal wire rack. The bowls were stacked upside down on top of one another and were wet inside and outside of the bowl's surfaces. During a concurrent interview with the certified dietary manager (CDM), he confirmed the bowls were stacked wet and he stated they should be air dried before being stacked and stored.
Review of the facility's policy titled Dishwashing Machine Use revised March 2010, indicated The following guidelines will be followed when dishwashing: . f. After running items through entire cycle, allow to air dry.
According to the 2017 Food and Drug Administration (FDA) Food Code, Section 4-901.11 Equipment and Utensils, Air-Drying Required, After cleaning and sanitizing, equipment and utensils: shall be air-dried . According to the FDA Food Code 2017 Annex 4-901.11 items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow.
2. During an initial kitchen tour on 7/15/24 at 9:10 a.m., accompanied by the certified dietary manager (CDM), in the walk-in freezer the following were observed:
a. One unopened 5-pound bag of yokisaba noodles with a manufacturer's use by date of 6/8/24 printed on the bag and 5 unopened packages of prosciutto with a manufacturer's use by date of 1/22/24 printed on the packages. During a concurrent interview with the CDM, he confirmed the noodles and prosciutto were beyond the use by date and he stated they should be discarded.
b. Two unopened 17.5 ounce packages of gnocci with spinach. The two packages were undated and had no manufacturer's use by date on the packages. During a concurrent interview with the CDM, he stated the packages had probably been removed from their original carton. He further stated the two packages of gnocci with spinach should be discarded since no use by dates were available on the packages.
Review of the facility's policy titled Food Receiving and Storage, revised July 2014, indicated All foods stored in the refrigerator or freezer will be covered, labelled, and dated (use by date).
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to ensure infection control practices were implemented when:
1. Foley catheter ((F/C: a semi-flexible plastic tube, one end inser...
Read full inspector narrative →
Based on observation, interview and record review, the facility failed to ensure infection control practices were implemented when:
1. Foley catheter ((F/C: a semi-flexible plastic tube, one end inserted into bladder (a body organ that stores urine] and the other end attached to a bag that collects urine)'s tubing (hard plastic tube attached between F/C and F/C's drain bag [urine collection bag] to drain urine from body) laying on floor for Resident 332;
2. Nasal Cannula (NC: a medical device to provide supplemental oxygen [O2: colorless, odorless, and tasteless gas supports life] to residents) tubes on floor and unchanged for Resident 334;
3. Licensed nurse failed to do hand hygiene after removing gloves; and
4. Phlebotomist (PHMT: person responsible to take samples of blood from residents for testing) was in the hallway with gloves on.
These failures could result in the spread of infections and cross-contamination that could affect all the residents residing in the facility.
Findings:
1. Review of Resident 332's face sheet (FS: a document that gives a resident's information at a quick glance) indicated Resident 332 was admitted to facility on 7/9/2024. Review of Resident 332's admission diagnoses including fracture of superior rim of left pubis (broken bone in pelvis [basin shaped complex of bones that connects the trunk and legs of the body]).
Review of Resident 332's physician order dated 7/9/2024 indicated, Foley Catheter Fr.16 (F/C size) due to diagnosis --- change per MD (medical doctor) schedule and PRN (as needed) obstruction.
During observation on 7/15/2024 at 9:27 a.m., noted Resident 332's F/C's tube on floor, left side next to Resident 332's bed.
During a concurrent observation and interview with license vocational nurse C (LVN C) on 7/15/2024 at 9:37 am., Resident 332's F/C tube on floor, LVN C acknowledged Resident 332's F/C's tube touched the floor. LVN C stated F/C's tube should be placed above the floor for infection control.
2. Review of Resident 334's FS indicated Resident 334 admitted to facility on 6/26/2024. Review of Resident 334's admission diagnoses including sleep apnea (a potential serious sleep disorder in which breathing repeatedly stops and starts), atrial fibrillation (an irregular, often rapid heart rate causes poor blood flow), and heart valve replacement (replaced damaged heart valve with a new synthetic material valve or animal tissue).
Review of Resident 334's physician orders dated 6/27/2024 indicated, Continuous O2 at night @ 2LPM (liters per minute: oxygen measured in liters per minute) via NC. Notify MD (medical doctor) if O2 sat (O2 level in blood) <90% every evening and night shift.
Review of Resident 334's physician order dated 6/27/2024 indicated, Change and date O2 tubing every night shift every Wed.
During an observation on 7/15/2024 at 10:29 a.m., noted NC tube attached to emergency oxygen tank (E tank: portable oxygen tank used to administer oxygen) was dated 7/4/2024, and NC tube was on the floor next to Resident 334's bed when O2 was not in use. Resident 334's room air concentrator (RAC: a medical device that take in air from the room and filter out nitrogen to provides higher amounts of oxygen) placed next to Resident 334's bed attached with another NC tube was also on floor when O2 was not in use.
During a concurrent observation and interview with LVN C on 7/15/2024 at 10:32 a.m., LVN C conformed Resident 334's NC tubes were on the floor, and E-tank NC tube changed on 7/4/2024. LVN C stated NC tubing should have placed in a bag when O2 was not in use and NC tube should have been changed every week on Wednesday. LVN C also stated nursing staff should have been changed NC tube on past Wednesday, and both NC tubes placed in a bag when O2 was not in use for infection control practices.
During an observation on 7/18/24 at 9:51 a.m., Resident 15's oxygen tubing was observed lying on the floor of his room, from the oxygen concentrator to Resident 15 who was lying in bed, which was approximately five to six feet distance.
During an interview on 7/15/24 at 10:50 a.m., with the Infection Preventionist (IP), IP stated the oxygen tubing should not be on the floor.
During an interview on 7/17/24 at 3:22 with the director of nursing (DON), the DON stated it is not ok to have long oxygen tubing on floor.
The facility did not have a P&P which covers not letting the NC and oxygen tubing rest on the floor.
3. During medication administration observation on 7/16/2024 at 8:45 a.m., with LVN C, observed LVN C donned (put on) both gloves, cleaned sphygmomanometer (medical device to monitor blood pressure [ BP: pressure of blood against walls of blood vessels]) and stethoscope (a medical device to listen internal sounds of human body) with a sanitizing wipe. LVN C doffed (removed) both gloves, discarded in garbage bin along with sanitizing wipe. LVN C taken medication cart keys from her uniform and opened medication cart and placed both devices inside the cart, no hand hygiene (HH) after removing gloves from both hands.
During an interview with LVN C on 7/16/2024 at 9:20 a.m., LVN C confirmed no HH was performed after gloves were removed. LVN C stated she should have washed hands after removing the gloves.
4. During a concurrent observation and interview with PHMT on 7/17/2024 at 8:27 a.m., PHMT walked in hallway with left hand glove on. PHMT acknowledged she walked in the hallway with a glove on her left hand. PHMT stated staff should not walk in hallway with gloves on. PHMT also stated staff should have removed gloves and washed hands before coming out to the hallway.
During an interview with facility's infection preventionist (IP) on 7/19/2024 at 8:37 a.m., IP stated nursing staff should have changed O2 NC tube every week and placed tube in a bag when O2 was not in use for infection control. IP also stated F/C tube should be above the floor for standard infection control practice.
During an interview with IP on 7/19/2024 at 9:29 a.m., IP stated PHMT should not wear gloves in hallway. IP also stated PHMT should have removed glove and washed hands before coming out to the hallway. IP further stated staff should have washed hands after removing gloves each time.
During facility's policy and procedure (P&P) titled, Departmental (Respiratory Therapy) Prevention of Infection, revised dated November 2011, the P&P indicated, Change the oxygen cannulae and tubing every seven (7) days, or as needed.
During review of facility's P&P titled, Handwashing/Hand Hygiene, revised dated October 2023, the P&P indicated, Hand hygiene is indicated:
g. immediately after glove removal.
During review of facility's P&P titled, Personal Protective Equipment-Gloves, revised July 2009, the P&P indicated, 2. Gloves shall be used only once and discard into the appropriate receptacle located in the room in which the procedure is being performed. 8. Wash hands after removing gloves.
Review of facility's P&P tilted, Catheter Care, Urinary, undated, the P&P indicated, Be sure the catheter tubing and drainage bag are kept off the floor.
Jun 2023
5 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure services were provided to meet the professiona...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure services were provided to meet the professional standard of practice for one of four residents (Resident 6) who had a pacemaker (implanted device for a heart condition, a battery-powered device implanted inside the heart to restore a normal heartbeat) when:
1. The resident's medical record had no pacemaker-paced rate information,
2. The licensed nurse did not develop a care plan to manage pacemaker care.
These failures had the potential to compromise Resident 6's health and safety.
Findings:
A review of Resident 6's clinical records indicated Resident 6 was admitted on [DATE] and had diagnoses including chronic diastolic (congestive) heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), and a pacemaker was implanted on 5/25/2022.
During a concurrent interview and record review with Licensed Vocational Nurse (LVN) A on 6/8/2023, at 3:17 p.m., LVN A confirmed Resident 6's medical record had no pacemaker-paced rate information, and no care plan to address the pacemaker care. LVN A stated, the pacemaker paced rate should be documented in the medical record, and nurses should have developed a care plan to monitor the malfunction of the pacemaker.
During a concurrent observation and interview with LVN A on 6/8/2023 at 3:20 p.m., in Resident 6's room, LVN A confirmed Resident 6 had a pacemaker in his left upper chest.The LVN stated she did not know the pacemaker-paced rate and should have known the paced rate to monitor pacemaker malfunction.
A review of the facility's policy and procedure (P&P), Pacemaker, Care of a Resident with a, revised 12/2015, the P&P indicated, for each resident with a pacemaker, document the following in the medical record and on a pacemaker identification card upon admission .paced rate
A review of CMS's RAI Version 3.0 Manual chapter 4.2, Overview of the Resident Assessment Instrument (RAI) and Care Area Assessments (CAAS) indicated the facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of 12 sampled residents (Resident 17) was free from unne...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of 12 sampled residents (Resident 17) was free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behaviors) when Resident 17 received Lorazepam (anxiolytic medication, used to reduce anxity)without a stop date.
The failure had the potential to result in inadequate use of psychotropic medications.
Findings:
A review of Resident 17's clinical record indicated she was admitted to the facility on [DATE] with diagnoses including unspecified dementia (a term used to describe a group of symptoms affecting memory, thinking, and social abilities severely enough to interfere with the patient's daily life), anxiety, and depression.
A review of Resident 17's physician's orders dated 5/19/2023 indicated administering Lorazepam 0.5 milligrams (mg, unit of measurement)1 tablet orally every 4 hours as needed (PRN) for anxiety manifested by restlessness.
During a concurrent interview and record review with the Director of Nursing (DON) on 6/9/2023 at 1:33 p.m., the DON confirmed that the PRN Lorazepam order for Resident 17 was without stop date, and more than 14 days from the order date. The DON stated that the PRN psychotropic medication order should have a stop date. It should not exceed 14 days for the first time order and should not exceed 90 days for the second-time order. The PRN Lorazepam order for Resident 17 should have a stop date and should be stopped in 90 days.
A review of the facility's policy and procedure titled Psychotropic Medication Use, effective date 12/01/07, indicated, PRN psychotropic medications should be ordered for no more than 14 days. Each resident who is taking a PRN psychotropic drug will have his or her prescription reviewed by the physician or prescribing practitioner every 14 days and also by the pharmacist every month .For psychotropic medications, if the attending physician believes a PRN order for longer than 14 days is appropriate, the attending physician can extend the prescription beyond 14 days for residents by documenting their rationale in the resident's medical record .the facility should not extend PRN antipsychotic orders beyond 14 days
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure medications and biologicals were stored and la...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure medications and biologicals were stored and labeled appropriately when:
1. Two unlabeled and opened bottles of Di-Dak-Sol diluted Dakin's solution (used to treat or prevent infections caused by cuts or abrasions, skin ulcers, pressure ulcers, diabetic foot ulcers, or surgery), and one unlabeled opened hydrocortisone cream 1% -topical (used to help relieve redness, itching, swelling, or other discomfort caused by skin conditions) were found in the treatment cart;
2. An expired and opened Fluocinolone acetonide Topical solution USP, 0.01% (used to reduce skin inflammation and relieve itching) and an expired opened Normal Saline solution (NSS) 100 milliliters (ml, a unit of measurement for volume) (mixture of sodium chloride in water and applied to the affected area or used to clean wounds) were inside the treatment cart;
3. One opened bottle of Doxazosin Mesylate (used in men to treat the symptoms of an enlarged prostate) in the medication cart had no change of direction label; and
4. One opened suture removal kit was found inside medication Cart A together with multiple house supply medication bottles.
These failures could result in the accidental administration of expired or contaminated medications or biologicals to the residents.
Findings:
1. During a concurrent observation and interview on [DATE] at 9:03 a.m., with licensed vocational nurse C (LVN C), the treatment cart had two opened bottles of Di-Dak-Sol diluted Dakin's solution with no expiration date, no resident's name and room number, and the label was ripped off. LVN C confirmed this observation and stated medications should have expiration date, label for instructions, resident's name, and room number. LVN C further stated these bottles should have been discarded.
During a concurrent observation and interview on [DATE] at 8:57 a.m., with LVN C, the treatment cart had one unlabeled opened hydrocortisone cream 1%. LVN C confirmed this observation and stated the hydrocortisone cream should have been labeled.
A review of the facility's policy and procedure, revised date 11/2020 titled Storage of Medication, indicated the nursing staff is responsible for maintaining medication storage and preparation areas in a safe, clean and sanitary manner. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.
2. During a concurrent observation and interview on [DATE] at 9:02 a.m., with LVN C, one opened and expired bottle of NSS 100 ml was found inside the treatment cart. LVN C confirmed the observation and stated the NSS expired on [DATE] and should have been discarded.
Review of the facility's policy, revised date [DATE] titled 8.2 Disposal /Destruction of Expired or discontinued Medication Manual title California LTC Facility's Services and Procedures Manual, indicated the facility should place all discontinued or outdated medications in a designated, secure location which is solely for discontinued medications or marked to identify the medications discontinued and subject to destruction Facility should dispose of outdated medications, discontinued medication in a timely fashion or no more than 90 days of the date the medication was discontinued by physician/prescriber.
3. During medication pass observation on [DATE] at 8:07 a.m., with LVN A, she gave Doxazosin Mesylate to Resident 15. The label on the bottle indicated, Doxazosin Mesylate tablet 4 milligrams (mg, a unit of measurement) one tablet at bedtime.
During a concurrent observation of medication cart A and interview with LVN A on [DATE] at 10:28 a.m., LVN A confirmed that the label on Resident 15's medication bottle of Doxazosin Mesylate tablet 4 mg indicated to take one tablet at bedtime. LVN A also confirmed the medication had been given in the morning ever since it was ordered on [DATE]. LVN A further stated that the medication came from an outside pharmacy and a direction change sticker should have been put on the outside of the bottle to prevent confusion.
During an interview on [DATE] at 10:33 a.m., with the Director of Nursing (DON), the DON stated that medications coming from outside pharmacies should be checked by licensed nurses. The DON stated if the directions on the bottles do not match the physician's orders, a sticker for change in direction should be put in place.
Review of the facility's policy, revised date [DATE] titled California LTC Center's Services and Procedures Manual Policy , indicated . 4.5 Reordering, Changing, and Discontinuing orders, indicated if an order has been changed and there is adequate supply on hand, the facility should notify the pharmacy to send a sticker or label indicating the change in directions. The policy further indicated the change in directions sticker should be applied to the existing supply of medications.
4. During a concurrent observation of medication cart A and interview with LVN A on [DATE] at 10:23 a.m., one opened suture removal kit tray was found inside medication cart A together with multiple house supplies (bulk medication shared by several residents)medication bottles. LVN A confirmed the observation and stated the removal kit tray should be stored inside the treatment cart, not mixed with the bottles of house supply medications.
A review of the facility's policy and procedure, revised date 11/2020 titled Storage of Medication, indicated the nursing staff is responsible for maintaining medication storage and preparation areas in a safe, clean and sanitary manner.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure food was stored, prepared, distributed, and ser...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food safety when:
1. A scoop was inside the dry legume container in the dry storage area;
2. There were opened, undated, unlabeled, and outdated food items in the food preparation and dry storage areas;
3. There were opened, undated, and unlabeled food items in the walk-in refrigerator;
4. There were undated, and unlabeled food items in the walk-in freezer.
These failures had the potential to cause food contamination and food-borne illness to 22 of 22 residents who received their food from the kitchen.
Findings:
During an initial kitchen tour on 6/5/23 at 8:25 a.m., accompanied by the director of dining services (DDS), the following observations were made in the facility's kitchen:
1. Inside the kitchen's dry storage area there was a plastic bin containing dry legumes with a scoop inside the bin. The scoop was touching the legumes. The DDS confirmed the scoop was inside the bin on top of the dry legumes. The DDS stated there was a scoop holder inside the bin that could be used to store the scoop but he confirmed the scoop was laying in the dry legumes, not inside the scoop holder.
Review of the facility's policy titled Food and Supply Storage, revised 1/23, indicated Dry Storage: Scoops may be stored in bins on a scoop holder. The food level must be no closer than one inch below the handle of the scoop.
2. There was an opened gallon container of barbeque liquid smoke on a shelf in the food preparation area. The label on the liquid smoke indicated it had a discard date of 5/1/23. The DDS confirmed the liquid smoke was beyond the discard date and he stated the liquid smoke must be discarded.
Inside the kitchen's dry storage area, there was a plastic bag of uncooked bowtie pasta labeled with an open date of 12/15/22. There was a discard date of 5/1/23 on the pasta label. The DDS confirmed the pasta was beyond the discard date and he stated the pasta must be discarded.
There was a plastic bag containing 12 hot dog buns on a shelf in the food preparation area. There was no label on the hot dog buns. The DDS confirmed the hot dog buns had no label. He stated all food items should be labeled with an open date and a discard date. The DDS stated the hot dog buns must be discarded.
3. In the walk-in refrigerator there was a metal container with three pieces of red meat inside covered with plastic wrap. There was no label and no date on the container. The DDS stated the red meat was filet [NAME] and he confirmed there was no label and no date on the container of red meat. The DDS stated the red meat must be discarded.
In the walk-in refrigerator there was an open 16-ounce container of whipped topping. There was no label and no date on the container. The DDS confirmed the whipped topping had no label and no date. He stated the whipped topping must be discarded.
During a kitchen tour on 6/6/23 at 8:15 a.m., accompanied by the DDS, the following observations were made in the facility's walk-in freezer:
4. There was a package with 12 frozen pizza flatbreads that was unlabeled and undated.
There was a package of 12 frozen tortilla rounds that was unlabeled and undated. There were 12 frozen turkey patties that were unlabeled and undated. There were 4 loaves of frozen rye bread that were unlabeled and undated. There were ice particles on the rye bread loaves and ice crystals at the bottom of the four rye bread bags. The DDS confirmed the presence of the ice particles in the bags of frozen rye bread.
The DDS confirmed the pizza flatbread, the tortilla rounds, the turkey patties, and the rye bread loaves had no label and were undated. He stated all food items should be labeled with an open date and a discard date. The DDS stated the pizza flatbread, the tortilla rounds, the turkey patties and the rye bread must all be discarded.
Review of the facility's policy titled Food and Supply Storage, revised 1/23, indicated Cover, label and date unused portions and open packages. Products are good through the close of business on the date noted on the label. Commercially produced foods may be held frozen until the manufacturer's expiration date, or for 3 months if no expiration date on the package.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff implemented proper infection control pra...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff implemented proper infection control practices when:
1. The licensed nurse did not change gloves between tasks;
2. Registered Nurse D (RN D) did not perform hand hygiene in between procedures;
3. Resident 127's spirometer (an apparatus for measuring the volume of air inspired and expired by the lungs- measures ventilation, the movement of air into and out of the lungs) mouthpiece was touching the side table;
4. Trash can attached to the Medication Cart B has used facial mask and N-95;
5. Three medication containers inside the medication room refrigerator has grayish substance, and disposal container for discontinued and refused medication had red spots of liquid substance inside the medication room;
6. There was a grayish powder seen in the first drawer of the treatment cart.
7. The Medication Cart A had a bottle of Milk of Magnesia oral- MOM (a laxative to relieve occasional constipation and used as an antacid to relieve indigestion, sour stomach, and heartburn) liquid with dried whitish substance outside the bottle cover, and the oral hygiene solution (The natural Dentist Healthy gums liquid/oral rinse- mouth wash) has greenish substance outside the cup cover.
These failures had the potential to result in cross-contamination and the spread of infection among residents and staff.
Findings:
1. A review of Resident 6's clinical records indicated he was admitted on [DATE] and had diagnoses including bacteremia (viable bacteria in the blood) and lobar pneumonia (acute exudative inflammation of the entire lobe of a lung).
A review of Resident 6's physician order dated [DATE] indicated to infuse Ceftriaxone(medication used to treat certain infections caused by bacteria) 2-gram solution /50 ml. (milliliter, unit of volume in the metric system) at 100 ml/hr (milliliter/ hour) over 30 minutes for pneumonia IV (intravenous therapy, uses a type of tiny plastic tubing that goes into the vein, a needle, and plastic tubing that connects the set-up to a bag of fluid) for 37 Days.
During a concurrent observation and interview with Registered Nurse B (RN B) on [DATE] at 3:05 p.m., in Resident 6's room, Resident 6 had a peripherally inserted central catheter (PICC, a long, thin tube that's inserted through a vein in patients' arm and passed through to the larger veins near patients' heart) on his right upper arm. RN B disinfected the PICC line port with an alcohol swab, flushed the port with 10 ml. (milliliter, unit of measurement) prefilled normal saline, set up the IV pump machine and connected the IV line to the PICC line port with the same pair of gloves. RN B acknowledged that she should have changed gloves between tasks. RN B stated that using one pair of gloves to perform multiple tasks might cause cross-contamination.
A review of the facility's policy and procedure(P&P) titled Standard Precautions Revised [DATE], the (P&P) indicated Gloves are changed as necessary, during the care of a resident to prevent cross-contamination . (When moving from a dirty site a clean one) . Gloves are not to be reused . Gloves are removed promptly after use, before touching non-contaminated items .
2. During the medication pass observation on [DATE] at 9:55 a.m., RN D touched the bedside table, gave the oral medication to Resident 3 without performing hand hygiene then went to the medication cart to get the drinking straw, opened the drinking straw and put it inside the cup of juice and gave to the Resident 3 without performing hand hygiene.
During an interview on [DATE] at 10:16 a.m., with RN D, she confirmed the above observation and stated that she should have performed hand hygiene in between procedure to prevent contamination.
Review of the facility policy dated 8/2019, titled Handwashing/ Hand Hygiene, indicated this facility considers hand hygiene the primary means to prevent the spread of infections All personnel shall follow the handwashing/ hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non- antimicrobial) and water for the following situations: before and after direct contact with residents; before preparing or handling medications; after contact with objects in the immediate vicinity of the resident.
3. During an initial tour of the facility on [DATE] at 9:10 a.m., Resident 127's spirometer mouthpiece was touching the side table.
During a concurrent observation and interview on [DATE] at 9:14 a.m., Licensed vocation nurse C (LVN C) confirmed the above observation. LVN C stated that the spirometer apparatus mouthpiece should not be touching the bedside table surface and it should be put inside the plastic bag.
4. During an initial tour of the facility on [DATE] at 9:06 a.m., trash can attach to the medication cart B has one used facial mask and one N-95 that were exposed.
During a concurrent observation and interview on [DATE] at 9:07 a.m., with RN D, she confirmed the above observation. She stated that she just throws the N-95 inside the trash can that was attached to the medication cart and changed to facial mask and vice versa when passing medications to the different residents. She further stated that N-95 and facial mask should not be disposed inside the trash can attach to the medication cart B to prevent contamination and spread of infection.
5. During a medication room observation on [DATE] at 8:28 a.m., 8:41a.m., with LVN C, three medication containers inside the medication room refrigerator have grayish substance and the disposal container cover for discontinued/ refused medication had multiple red spots of liquid substance on top of the cover. LVN C acknowledge the observation and stated that the refrigerator's three medication containers and disposal container cover need to be clean to prevent contamination.
6. During an observation of treatment cart on [DATE] at 8:55 a.m., with LVN C, Inside the first drawer has grayish powder substance together with multiple treatment supplies that was stored. LVN C confirmed the observation and stated the treatment cart need to be clean to prevent contamination.
7. During an observation of medication cart A on [DATE] at 10:28 and 10:29 a.m., with LVN A, MOM liquid has dried whitish substance outside the bottle cover and the natural Dentist Healthy gums liquid/oral rinse( mouth wash) has greenish substance around the outside cup cover stored inside the medication cart A. LVN A acknowledge the observation and stated that it should have been clean and wipe after used to prevent contamination.
A review of the facility's policy and procedure, revised date 11/2020 titled Storage of Medication, indicated the nursing staff is responsible for maintaining medication storage and preparation areas in a safe, clean and sanitary manner.
May 2019
3 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure residents administer medications correctly to themselves for one of two residents receiving eye drops. For Resident 19...
Read full inspector narrative →
Based on observation, interview, and record review, the facility failed to ensure residents administer medications correctly to themselves for one of two residents receiving eye drops. For Resident 19, the facility failed to ensure she was taught and monitored how she administered her own eye drops. This failure had the potential of Resident 19 contracting an eye infection.
Findings:
During a medication administration observation on 5/1/19 at 8:16 a.m., licensed vocational nurse A (LVN A) handed Resident 19 a bottle of eye drops. While Resident 19 was administering her own eye drops, she touched the dropper tip to her eye. LVN A did not offer Resident 19 any education or instruction on how to use the eye dropper.
During an interview with LVN A on 5/1/19 at 8:36 a.m., he stated he encouraged the residents to administer their own eye drops and inhalers in order to prepare them when they returned home.
During an interview with Resident 19 on 5/3/19 at 2:43 p.m., she stated she might have touched the dropper tip to her eye.
During an interview with LVN A on 5/3/19 at 2:55 p.m., he stated he had not taught Resident 19 any instruction or proper administration technique on use of the eye dropper. He just watched her.
The facility's policy and procedure, 6.0 General Dose Preparation and Medication Administration revised on 1/1/13, indicated .5.7 Provide the resident with any necessary instructions (e.g., using an inhaler).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure residents stay free from infection for one of two residents receiving eye drops. For Resident 19, the facility failed ...
Read full inspector narrative →
Based on observation, interview, and record review, the facility failed to ensure residents stay free from infection for one of two residents receiving eye drops. For Resident 19, the facility failed to educate and monitor her use of eye dropper which had the potential of Resident 19 contracting an eye infection.
Findings:
During a medication administration observation on 5/1/19 at 8:16 a.m., licensed vocational nurse A (LVN A) handed Resident 19 a bottle of eye drops. While Resident 19 was administering her own eye drops, she touched the dropper tip to her eye. LVN A did not offer Resident 19 any education or instruction on use of the eye dropper, nor offer her hand hygiene prior to administering the eye drops.
During an interview with LVN A on 5/1/19 at 8:36 a.m., he stated he encouraged the residents to take their own eye drops & inhalers for when they go home.
During an interview with LVN A on 5/3/19 at 8:03 a.m., he stated touching the tip of the eye dropper to Resident 19's eye could be an infection control issue.
During an interview with the director of nursing (DON) on 5/3/19 at 2:35 p.m., she stated if Resident 19 touched the dropper to her eye, it needed to be thrown away and reordered right away.
During an interview with Resident 19 on 5/3/19 at 2:43 p.m., she stated she might have touched the dropper tip to her eye.
During an interview with LVN A on 5/3/19 at 2:55 p.m., he stated he had not taught Resident 19 any instruction or proper administration technique on use of the eye dropper. He just watched her.
The facility's policy and procedure, 6.0 General Dose Preparation and Medication Administration revised on 1/1/13, indicated .3.5 If a medication which is not in a protective container is dropped, Facility staff should discard it according to Facility policy.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation,interview and record review the facility failed to ensure food was stored, prepared, and served under sanitary conditions when foods were not labeled and dated. The kitchen staff ...
Read full inspector narrative →
Based on observation,interview and record review the facility failed to ensure food was stored, prepared, and served under sanitary conditions when foods were not labeled and dated. The kitchen staff did not demonstrate changing gloves in between tasks. These failures had the potential to affect safety in food consumption as well as cross contamination of food.
Findings:
During an initial kitchen tour observation on 5/1/19 at 8:17 a.m., with the dietary manager an open bag of vegetables had no opening date, two bags of noodles had an expiration date of 3/17/17. One bag of black garlic had no use by or expiration date. An open tartar (a cold sauce, typically eaten with fish, consisting of mayonnaise mixed with chopped pickles, capers) sauce had no open date. An open bag of thyme was unlabelled/undated and had a brown discoloration. The dietary aid B (DA B) changed the trash bin liners and went to the dish rack turned on the faucet and did not change gloves or wash hands.
During a concurrent interview with the dietary manager, she confirmed the above observation.
During an observation on 5/2/19 at 11:02 a.m., DA C was observed chopping broccoli with gloved hands. He then went to the sink and turned on the faucet to wash the broccoli without changing gloves.
Concurrent he dietary manager stated the kitchen staff should have changed their gloves after chopping the broccoli and also when touching trash bin liners.
The facility's 1/2019 policy, Food and Supply Storage, indicated all food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. Procedures: Cover, label and dated unused portion and open package. All associates handling foods shall wash hands before handling food or clean utensils/dishes/equipment.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Grade B+ (80/100). Above average facility, better than most options in California.
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most California facilities.
- • 40% turnover. Below California's 48% average. Good staff retention means consistent care.
Concerns
- • 22 deficiencies on record. Higher than average. Multiple issues found across inspections.
Bottom line: Generally positive indicators. Standard due diligence and a personal visit recommended.
✓ Report will be sent to your email
About This Facility
What is Health Care Ctr At The Forum At Rancho San Antonio's CMS Rating?
CMS assigns HEALTH CARE CTR AT THE FORUM AT RANCHO SAN ANTONIO an overall rating of 5 out of 5 stars, which is considered much above average nationally. Within California, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Health Care Ctr At The Forum At Rancho San Antonio Staffed?
CMS rates HEALTH CARE CTR AT THE FORUM AT RANCHO SAN ANTONIO's staffing level at 5 out of 5 stars, which is much above average compared to other nursing homes. Staff turnover is 40%, compared to the California average of 46%. This relatively stable workforce can support continuity of care. RN turnover specifically is 62%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Health Care Ctr At The Forum At Rancho San Antonio?
State health inspectors documented 22 deficiencies at HEALTH CARE CTR AT THE FORUM AT RANCHO SAN ANTONIO during 2019 to 2024. These included: 22 with potential for harm.
Who Owns and Operates Health Care Ctr At The Forum At Rancho San Antonio?
HEALTH CARE CTR AT THE FORUM AT RANCHO SAN ANTONIO is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility operates independently rather than as part of a larger chain. With 48 certified beds and approximately 38 residents (about 79% occupancy), it is a smaller facility located in CUPERTINO, California.
How Does Health Care Ctr At The Forum At Rancho San Antonio Compare to Other California Nursing Homes?
Compared to the 100 nursing homes in California, HEALTH CARE CTR AT THE FORUM AT RANCHO SAN ANTONIO's overall rating (5 stars) is above the state average of 3.2, staff turnover (40%) is near the state average of 46%, and health inspection rating (4 stars) is above the national benchmark.
What Should Families Ask When Visiting Health Care Ctr At The Forum At Rancho San Antonio?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Health Care Ctr At The Forum At Rancho San Antonio Safe?
Based on CMS inspection data, HEALTH CARE CTR AT THE FORUM AT RANCHO SAN ANTONIO has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 5-star overall rating and ranks #1 of 100 nursing homes in California. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Health Care Ctr At The Forum At Rancho San Antonio Stick Around?
HEALTH CARE CTR AT THE FORUM AT RANCHO SAN ANTONIO has a staff turnover rate of 40%, which is about average for California nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Health Care Ctr At The Forum At Rancho San Antonio Ever Fined?
HEALTH CARE CTR AT THE FORUM AT RANCHO SAN ANTONIO has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Health Care Ctr At The Forum At Rancho San Antonio on Any Federal Watch List?
HEALTH CARE CTR AT THE FORUM AT RANCHO SAN ANTONIO is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.