Anaheim Crest Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure two of five sampled residents for unnecessary medications (Residents 8 and 83) reviewed for informed consents were provided the right to self-determination regarding the use of the psychotropic medications and treatments. * The facility failed to ensure Resident 83's informed consent for the mirtazapine (antidepressant medication) showed nonpharmacological approaches used. Additionally, the prescribing physician did not sign the informed consent form. * The facility failed to ensure Resident 8's informed consents for the alprazolam (antianxiety medication), bupropion (antidepressant medication) and sertraline (antidepressant medication) showed whether the medications had caution and warning summary, FDA-approved use, and a black warning label. In addition, the facility failed to ensure the informed consent for alprazolam medication was signed by the prescribing physician. These failures posed the risk of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medications were safely administered for one of 74 residents (Resident 64). * Resident 64 had the Zoryve Cream 0.3% (a prescription medication used to treat inflammatory skin conditions) at bedside. However, Resident 64 did not have a physician's order to keep the medication at the bedside. This failure had the potential for the resident to administer the medication inaccurately, develop adverse reactions, and negatively affect the resident's well-being.Findings: Review of the facility's P&P titled Medication Labeling and Storage revised 2/2023 showed the facility stores all the medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. Review of the facility's P&P titled Administering Medications revised 4/2023 showed the residents may self-administer their own medications only if the attending physician,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to obtain and maintain a copy of the Advance Directive for one of seven final sampled residents (Resident 12) investigated for Advance Directives. * Resident 12's Advance Directive was not in the medical record. This failure had the potential to result in the resident's wishes regarding medical treatment and services not being followed if they became unable to make their own medical decisions.Findings: Review of the facility's P&P titled Advance Directives dated 9/2022 showed on admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident, if cognitively able to, would like to formulate an advance directive. In the event the resident is unable to formulate an advanced directive due to cognitive impairment or deemed by the medical doctor that the resident is incapable of making decisions on his or her own, the facility will provide information and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record, and facility P&P review, the facility failed to ensure one of 20 residents reviewed for functional assessments (Resident 3) was completely assessed. * The facility failed to ensure Resident 6's use of transfer pole was assessed and documented. This failure had the potential to result in unnecessary use of, ineffective and/ or lack of monitoring of transfer pole use which could negatively affect resident's practicable mental, physical, and psychosocial well-being.Findings: Review of the facility's P&P titled Managing Falls and Fall Risk dated 2/7/24, showed resident centered approaches to managing falls and fall risk includes use of non-restraining approaches might include exercise and balance training, a rearrangement of room furniture, improving footwear changing the lighting and transfer poles, etc. On 5/18/26 at 0607 hours, during initial tour to the facility, Resident 6 was observed lying in bed with bilateral poles at bedside, at the upper part of the bed.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the risk and development of pressure injuries for one of one final sampled resident (Resident 49) reviewed for pressure injuries. * The facility failed to provide a low air loss mattress for Resident 49 per the physician's order. This failure posed Resident 49 at risk for the development or worsening of pressure injuries.Findings: Review of the facility's P&P titled Support Surfaces Guidelines revised 2/2024 showed a guideline for the assessment of appropriate pressure reducing and relieving devices for residents at risk of skin breakdown. Individuals at risk for developing pressure ulcers should be placed on a redistribution support surface such as a foam, gel, static air, alternating air, or air-loss when lying in bed. On 5/18/26 at 0821 and 1355 hours, Resident 49 was observed in his bed. A low air loss mattress was not observed. On 5/19/26 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided for two of three final sampled residents (Residents 13 and 79) reviewed for accidents. *Resident 13 had an unwitnessed fall incident on 5/7/26. Resident 13's post-fall neurological assessment was incomplete. * The facility failed to ensure the safe smoking practices were followed for one resident who smoked in the facility as evidenced by Resident 79 who was assessed as requiring supervision while smoking and with a history of non-compliance with the facility's smoking P&P was permitted to keep the cigarettes, lighters, and other smoking articles/materials in his possession. These failures had the potential for adverse outcomes related to accidents.Findings: Review of the facility's P&P titled Neurological Assessment (Routine) revised 10/2023 showed a routine neurological assessment is conducted to evaluate the resident for small changes over time that may…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of two final sampled residents (Resident 49) reviewed for nutrition received an acceptable nutritional service. * The facility failed to monitor weekly weights for Resident 49 per physician's orders. This failure had the potential risk of nutritional interventions not being implemented in a timely manner.Findings: Review of the facility's P&P titled Weight Assessment and Intervention revised 3/2022 showed the resident weights were monitored for undesirable or unintended weight loss or gain. A weight loss of 5% within a month was significant, a weight loss greater than 5% within a month was severe. Residents were weighed upon admission and at intervals established by the interdisciplinary team. Medical record review for Resident 49 was initiated on 5/18/26. Resident 49 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 49's H&P examination dated 5/4/26, showed Resident 49 had the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to provide the necessary care and services to maintain the intravenous (IV) accesses for one of one final sampled resident (Resident 68) reviewed for IV therapy. * The facility failed to ensure the midline line external catheter baseline measurements were obtained and documented for Resident 68. This failure had the potential to delay the identification of IV catheter related complications for the resident.Findings: Medical record review for Resident 68 was initiated on 5/18/26. Resident 68 was admitted to the facility on [DATE]. On 5/18/26 at 0615 hours, during an observation, Resident 68 was in bed asleep with a midline IV on the left upper arm with two lumen and a transparent dressing. Review of Resident 68's Order Summary Report showed the following physician's orders:- dated 4/22/26, an antimicrobial disc will be utilized for midline site and changed every seven days with dressing change, one time a day every Friday;- dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure appropriate pain management for one of one final sampled residents (Resident 49) reviewed for pain management. * The facility failed to administer Resident 49's prescribed lidocaine patch (a topical adhesive patch containing the local anesthetic lidocaine, designed to deliver the medication directly through the skin to numb a specific area) per the physician's orders. In addition, the facility failed to ensure the nonpharmacological interventions were provided for Resident 49 prior to the administration of his pain medication and the side effects of the pain medication were monitored per Resident 49's care plan. These failures had the potential to result in ineffective pain management and unnecessary discomfort for Resident 49.Findings: Review of the facility P&P titled Care Plans, Comprehensive Person-Centered revised 3/2022 showed a comprehensive, person-centered care plan that includes measurable…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the dialysis care and services were provided for one of one final sampled resident (Residents 7) reviewed for dialysis care. * The facility failed to ensure the Dialysis Communication Forms for Resident 7 were completed and accurate on multiple dates. This failure had the potential of not identifying negative outcomes for Resident 7.Findings: Review of the facility's P&P titled Hemodialysis Catheters- Access and Care of revised 2/2023 showed the residents with end stage renal disease (ESRD) will be cared for according to currently recognized standards of care. On 5/18/26 at 0930 hours, an observation and interview were conducted with Resident 7. Resident 7 stated he received hemodialysis treatment three times a week. Resident 7 showed he has a Permacath on the right upper chest. Medical Record Review for Resident 7 was initiated on 5/18/26. Resident 7 was admitted to the facility on [DATE]. Review of Resident 7's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, medical record review, and facility document review, the facility failed to ensure the facility staffs (RN 1, RN 2, and LVN 7) had specific competencies and standard of practice skill sets needed to provide the safe and efficient nursing care to the residents. * The facility failed to ensure RNs 1 and 2 were competent on assessing the Permacath (dialysis access) for Resident 7. * The facility failed to ensure LVN 7 demonstrated competency in the administration of the ophthalmic medication and nasal spray medication. These failures had the potential to put the residents at risks of the care not provided in a safe and competent manner. Findings: 1. Review of the facility's document titled Registered Nurse Supervisor job description undated showed the essential duties and responsibilities of a registered nurse supervisor includes assessment and development of resident care plans. Review of the facility's document In-Service training Lesson Plan titled Care for Dialysis patients and Documentation dated 2/12/26, showed the content of the in service…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary pharmaceutical services to ensure accurate administration and reconciliation of the medications. * The facility failed to ensure LVN 7 administered eye drops and nasal spray correctly to Resident 53. * The facility failed to ensure Resident 66's hydrocodone-acetaminophen (an opioid medication used to manage moderate to severe pain) tablet was documented administered in resident's MAR when the Antibiotic or Controlled Drug Record showed hydrocodone-acetaminophen was taken from Medication Cart A narcotic drawer. * The facility failed to ensure LVN 11 flushed Resident 67's GT with 15 ml of warm water in between medication as per facility's P&P. In addition, the facility failed to ensure LVN 11 administered the correct Pro-Stat (supplement) to Resident 67. * The facility failed to ensure the controlled medication count during the change of shift was completed and the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of five sampled residents (Resident 2) reviewed for unnecessary medications were free from unnecessary medications. * The facility failed to monitor the side effects for the use of Eliquis (blood thinner medication) for Resident 2. This failure had the potential for adverse effects related to the medication use.Findings: Review of Daily Med, for Eliquis-apixaban tablet revised 2/2025 under the Warnings and Precautions section, showed the Eliquis medication increased the risk of bleeding and can cause serious, potentially fatal bleeding. Review of the facility P&P titled Care Plans, Comprehensive Person-Centered revised 3/2022 showed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Medical record review for Resident 2 was initiated on 5/18/26. Resident 2…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 7.69%. One of the four licensed nurses (LVN 7) who were observed during medication administration was found to have errors. * LVN 7 failed to ensure the sodium chlorine (mineral and electrolyte supplement) medication was administered to Resident 60 with meals as per the physician's order. * LVN 7 failed to administer the correct artificial tears eye drops to Resident 53. These failures created the risk for the residents to have potential side effects or complications related to the medications including gastrointestinal discomfort from improper sodium chloride administration, and ineffective or inappropriate treatment related to the administration of incorrect sodium ophthalmic medication formulation.Findings: 1. On 5/19/26 at 1138 hours, a medication administration observation for Resident 60 was conducted with LVN 7. LVN 7 prepared two…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility P&P review, the facility failed to ensure safe medication storage in one of three medication carts (Medication Carts A) and one of one medication room inspected. * The facility failed to ensure Medication Room A was closed and locked at all times. * The facility failed to ensure internal and external medications were stored separately in Medication Room A. * The facility failed to ensure disposal of medication was signed by two nurses. These failures had the potential for the residents to be exposed to the expired medications and the potential to lead to medication errors and place the residents at risk of receiving the wrong type of medication. Findings: 1. Review of the facility's P&P titled Medication Labeling and Storage revised on February 2023 showed the facility stores all the medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. On 5/18/26 at 0540 hours, during…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, medical record, facility record review, and facility P&P review, the facility failed to ensure one of 69 residents served with meal trays (Resident 3) the recipe was followed and prepared appropriately. * The facility failed to ensure Resident 3's chopped meat diet as ordered by the physician is followed and prepared appropriately. This had the potential for the resident not receiving adequate nutrition, and appropriate servings.Findings: Review of the facility's P&P titled Therapeutic Diets dated October 2017 showed the following- diet will be determined in accordance with the residents' informed choices, preferences, treatment goals and wishes. Diagnosis alone will not determine whether the resident is prescribed a therapeutic diet.- a therapeutic diet must be prescribed by the resident's attending physician (or non-physician provider). The attending physician may delegate this task to a registered or licensed dietitian as permitted by state law.- diet order should match the terminology used by the food and nutrition services department.- if a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and facility document review, the facility failed to ensure the residents' care equipment were maintained in a safe operating condition. * The facility failed to ensure to monitor the Assure Platinum Blood Glucose Monitor control for one of two Assure Platinum Blood Glucose Monitor machines for Medication Cart A. This failure had the potential to result in inaccurate blood glucose readings and compromised resident care. * The facility failed to ensure the medication refrigerator in Medication Room A was free from any ice buildup. This failure had the potential to affect the stability and integrity of temperature sensitive medications.Findings: 1. Review of the Assure Platinum Blood Glucose Monitoring System Quality Assurance/ Quality Control Reference Manual revised [DATE] showed in section B Performing a Control Solution Test healthcare professionals perform control solution tests in accordance with the state regulatory guidelines. Check meter and test strips using Assure Dose…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to protect the residents' personal privacy for two of four sampled residents (Residents 1 and 2). * The facility failed to ensure the consent for photography was obtained for Residents 1 and 2, when videos were made of the residents without their permission and posted to the social media. This posed the risk of negatively affecting the residents' dignity.Findings: Review of the facility's P&P titled Confidentiality of Information and Personal Privacy revised on 10/2021 showed release of resident information, including video, audio, or computer stored information, will be handled in accordance with the resident rights and privacy policies. Review of the facility's P&P titled Photography, Video, Audio, and Electronically Recorded Data (undated) showed before taking any photographs or recordings for marketing or promotional purpose, written consent shall be obtained from the patient or authorized legal representative with the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the Transfer, Discharge Notices were given to Resident 1, 2, and 3's Responsible Party during the transfer to the acute care hospital. * Resident 1 was transferred to the acute care hospital on 1/10/26. The Transfer, Discharge Notice was documented as sent to the acute care hospital. * Resident 2 was transferred to the acute care hospital on 3/3/26. The Transfer, Discharge Notice was documented as sent to the acute care hospital. * Resident 3 was transferred to the hospital on [DATE]. The Transfer Discharge Notice was documented as sent to the acute care hospital. These failures had the potential to negatively impact the residents' health outcomes.Findings: According to the State Operations Manual (SOM) Appendix PP, Guidance to Surveyors for Long Term Care Facilities under S483.15(c)(3) Notice before transfer: Before a facility transfers or discharges a resident, the facility must (i)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to implement the P&P to ensure the reporting of a reasonable suspicion of a crime in accordance with Section 1150B for one of four sampled residents (Resident 1). * The facility failed to ensure Resident 1's sexual abuse allegation by a facility staff was reported timely to the CDPH L&C Program. This failure had the potential for abuse to go unreported and uninvestigated timely at a facility with a highly vulnerable resident population. Findings: Review of the facility's P&P titled Abuse Investigation and Reporting (undated) showed all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility administrator, or his/her designee, to the following persons or agencies:a. The State licensing/certification agency responsible for surveying/licensing the facility;b. The local/State…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the kitchen utensils were clean and free of food particles or residue. * The facility failed to ensure the kitchen utensils had a smooth cleanable surface and were in good condition. * The facility failed to ensure the heavy-duty blenders used for puree preparation, the clear plastic pitchers, and a measuring pitcher used for beverages were air dried prior to storing and stacking. * The facility failed to ensure the sanitary condition of the hood over the stove was maintained. These failures had the potential for cross contamination and foodborne illnesses for the residents consuming the food prepared in the facility's kitchen. Findings: Review of the facility's Report dated 6/22/25, showed 69 of 72 residents consumed the foods prepared in the kitchen. 1. Review of the facility's P&P titled Sanitization revised 11/2022 showed all the equipment, food contact surfaces and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to determine if it was safe for one nonsampled Resident (Resident 14) to self-administer the medication. * Resident 14 was observed with a medication at the bedside. Resident 14 had no physician's order, assessment, and a care plan for the self-administration of the medications. This failure had the potential for Resident 14 to administer the medication inaccurately. Findings: Review of the facility's P&P titled Self-Administration of Medication revised 2/2021 showed the residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. - As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. - If it is deemed safe and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the call lights were within reach for two of 19 final sampled residents (Residents 40 and 50). This failure had the potential for Residents 40 and 50 not to receive care and assistance when needed. Findings: Review of the facility's P&P titled Answering the Call Light revised 9/2022 showed to ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor. 1. Medical record review for Resident 40 was initiated on 6/22/25. Resident 40 was admitted to the facility on [DATE]. Review of Resident 40's H&P examination dated 4/2/25, showed the resident had the capacity to understand and make decisions. Review of Resident 40's care plan titled Visual Function initiated on 4/8/25, showed the interventions included to keep the call light within reach. On 6/22/25 at 0840 hours, a concurrent observation and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to develop the resident-centered care plans to reflect the individual care needs of two of 19 final sampled residents (Residents 34 and 48) * Resident 48's Care Plan addressing the resident's Mood and Behavioral Symptoms dated 1/29/24, did not include the interventions consistent with the interventions on the Informed Consent Renewal- Psychoactive Medications dated 5/11/25. * The facility failed to develop a comprehensive individualized care plan to address the interventions to address the PASARR (Preadmission Screening and Resident Review) Level II recommended interventions for Resident 34. These failures posed the risk of not providing the appropriate and individualized care to Residents 34 and 48 to meet the highest practicable mental health and well-being. Findings: 1. Review of the facility's P&P titled Care Planning- Interdisciplinary Team dated March 2022 showed a comprehensive,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and facility P&P review, the facility failed to ensure the medications were handled securely, accurately labeled, and stored appropriately. * The facility failed to dispose of the expired medication supplies and store the treatment cream separate from the food thickener. This failure had the potential to result in cross-contamination of the medications and posed the risk of non-licensed staff members having access to the medications. Findings: Review of the facility's P&P titled Medication Labeling and Storage dated 2/2023 showed the compartments (including but not limited to the drawers, cabinets, rooms, refrigerators, carts, and boxes) containing the medications and biologicals are locked when not in use and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others. The nursing staff are responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner. On 6/22/25 at 0950 hours, a concurrent observation and interview was conducted with the MDS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the menus were followed and the resident nutritional needs were met when the correct portion sizes were not followed for the Mandarin Oranges. This failure had the potential for 10 out of 69 residents receiving pureed food prepared in the kitchen to not meet their nutritional needs, which may lead to nutritional related health complications. Findings: Review of the facility's P&P titled Portion Control (undated) showed the residents will receive the appropriate portions of food as planned on the menu. Control at the point of service is necessary to assure that only the standard portion is served. Serving too small of portions results in the residents not receiving the nutrients needed. Serving too large of portions increases the costs as well as gives the residents more food than they need or are allowed to have (in the case of special diets). Review of the Mandarin Oranges puree recipe showed a number 10 scoop (three ounces) was used per serving. On 6/24/25 at 1105…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the medical record for one of 19 final sampled residents (Resident 44) was accurate. * The facility failed to ensure Resident 44's information on the POLST was accurate. This failure had the potential for the resident's care needs not being met as their medical information was inaccurate. Findings: Review of facility's P&P titled Charting and Documentation revised 7/2017 showed documentation in the medical record will be objective, completed, and accurate. Medical record review for Resident 44 was initiated on 6/22/25 . Resident 44 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Review of Resident 44's POLST under Section D - Information and Signatures dated 5/29/25, showed the box for the Advance Directive not available was checked. On 6/22/25 at 1621 hours, an interview and concurrent medical record review was conducted with the SSD. The SSD stated Resident 44 did have a Durable…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. Review of the facility's P&P titled Cleaning and Disinfection of Resident-Care Items and Equipment revised 9/2022 showed the resident-care equipment, including reusable items and durable medical equipment will be clean and disinfected according to current CDC (Center of Disease Control and Prevention - service organization that protects the public's health) recommendations for disinfection. On 6/22/25 at 0852 hours, during a general observation of the facility, LVN 1 was in Resident 40's room to verify the call light was on the floor. LVN 1 did not clean the call light when the LVN picked up the call light from the floor, put it on Resident's 40's bed then proceeded to wash her hands. LVN 1 was informed the call light was not cleaned when it was picked up from the floor. LVN 1 stated she should have cleaned the call light before putting it back on the bed for the resident to prevent the spread of infection. On 6/23/25 at 1550 hours, an interview with the DON was conducted in the DON's office. The DON was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to implement the P&P for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when the facility did not report an allegation of abuse to the CDPH, L&C Program for one of seven sampled residents (Resident 5). This failure had the potential for Resident 5 to be vulnerable to further abuse and emotional distress. Findings: Review of the facility's P&P titled Policy on Abuse Prevention and Mandated Reporting (undated) showed all alleged violations involving abuse, neglect, exploitation, or mistreatment including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator or his/her designee to the State licensing/certification agency responsible for surveying/licensing the facility. Alleged abuse, neglect, exploitation, or mistreatment will be reported within two hours if the alleged events have resulted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen when: * The facility failed to monitor for Time/Temperature Control for Safety (TCS) foods (food that require time and temperature controls to limit the growth of illness causing bacteria) to ensure proper cool down process was followed. * The facility failed to ensure the proper hand hygiene was practiced by dietary staff in the kitchen. * The facility failed to ensure the food past the use-by date was discarded. * The facility failed to ensure the items in the refrigerator were labeled correctly. * The facility failed to properly air-dry the kitchen equipment. * The facility failed to ensure the vendors donned their hair restraints or beard restraints in the kitchen. * The facility failed to ensure the kitchen utensils and equipment were stored or kept in sanitary conditions. * The facility failed to ensure the kitchen utensils were in good condition. * The facility failed to ensure the cutting boards…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the reasonable accommodations to meet the needs of two of 22 final sampled residents (Residents 3 and 115). * The facility failed to ensure Residents 115's call light and remote control for the bed were within resident's reach. * The facility failed to ensure Resident 3's call light was within the resident's reach. These failures had the potential to negatively impact the residents' psychosocial well-being or result in a delay to receive care. Findings: Review of the facility's undated P&P titled Answering Call Light showed to ensure timely responses to the resident's requests and needs and ensure the call light is accessible to the resident when in bed, from toilet, from shower or bathing facility and from the floor. 1. On 5/28/24 at 0843 hours, during the initial tour of the facility, Resident 115's call light and bed remote control were observed to be hanging on the bedside drawer handle that was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to notify the resident's representatives of the transfer and reasons for the transfer to the acute care hospital in writing and send a copy of the notice of transfer to the representative of the Office of the State Long-Term Care (LTC) Ombudsman for one of two sampled residents (Resident 19) reviewed for hospitalization. This failure posed the risk of the resident's representatives not being aware of their appeal rights and the Ombudsman not being aware of the circumstances of the resident's transfer/discharge should an appeal be filed or requested by the resident or their representatives regarding the transfer. Findings: Review of the facility's P&P titled Transfer or Discharge, Facility Initiated dated 10/2022 showed the resident and representative are notified in writing of the following information: a. The specific reason for transfer or discharge, including the basis; b. The effective date of transfer or discharge; c.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the resident or the resident's representative was provided a written bed hold policy upon transfer to the acute care hospital for one of two sampled residents (Resident 19) reviewed for hospitalization. This failure had the potential for the resident or the resident's representative to not be informed of their rights to return to the facility following a hospitalization. Findings: Review of the facility's P&P titled Transfer or Discharge, Facility Initiated dated 10/2022 showed the resident and representative are notified in writing of the following information: a. The specific reason for transfer or discharge, including the basis; b. The effective date of transfer or discharge; c. The specific location to which the resident is being transferred or discharged ; d. An explanation of the resident's right to appeal the transfer or discharge to the state, including: 1. the name, address, email, and telephone number of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to provide the necessary care and services to ensure one of three closed record review sampled residents (Resident 78) attained and maintained the highest practicable physical well-being. * Resident 78's had an order for stat (a common medical abbreviation for urgent or rush, means immediately) chest x-ray on [DATE] at 1019 hours. Resident 78's chest x-ray result received was dated [DATE] at 1954 hours, more than a day later, when the stat x-ray was ordered. This failure posed the risk for delayed care and intervention to Resident 78. Findings: Review of the facility's P&P titled Lab and Diagnostic Test Results - Clinical protocol revised 11/2018 showed the physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. The staff will process test requisitions and arrange for tests. The laboratory, diagnostic radiology provider, or other source will report test results to the facility. A nurse…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the dialysis care was provided for two final sampled residents reviewed for dialysis treatment (Residents 32 and 39). * Resident 39's fluid intake documented in the MAR was inconsistent with the fluid intake documented in the Fluid Intake with Meals form. * The facility failed to ensure dialysis communication forms for Resident 32 were completed and accurate. These failures had the potential for Residents 32 and 39 not being provided with the appropriate care and treatment. Findings: 1. Review of the facility's P&P titled Intake, Measuring and Recording revised 10/10 showed the purpose of the policy is to accurately determine the amount of liquid a resident consumes in a 24-hour period. Medical record review for Resident 39 was initiated on 5/30/24. Resident 39 was admitted to the facility on [DATE]. Resident 39 had diagnoses including end stage renal disease (kidneys no longer function) requiring dialysis three…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medications and biologicals were stored and disposed of properly. * The facility failed to ensure the medication for the discharged resident (Resident 684) was disposed of. * The facility failed to ensure two medication carts (Medication Carts 1 and 3) and the supplies were maintained in a sanitary condition. * The facility failed to ensure proper storage of the IV medication for Resident 75 in Medication room [ROOM NUMBER]. * The facility failed to ensure safe storage of ibuprofen (used to treat mild to moderate pain) and hydrogen peroxide (used to treat minor cuts and scrapes) spray bottle found at Resident 21's bedside. These failures had the potential to result in the unsafe medication administration, cross-contamination of the medications and posed the risk for other residents to have access to the medications. Findings: Review of the facility's P&P titled Disposal of Medications and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of 22 final sampled resident (Resident 52) was provided with the prescribed therapeutic diet. * Resident 52 was prescribed with fortified/high protein diet pureed/level 4 texture, thin consistency. Resident 52 was served with fortified/high protein diet pureed/level 4 texture double portions. This failure posed the risk of resident's nutritional needs not being met. Findings: Review of the facility's P&P titled Therapeutic Diets revised 10/2017 showed the therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences. Medical record review for Resident 52 was initiated on 5/29/24. Resident 52 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 52's Order Summary Report dated 5/30/24, showed the physician's order dated 5/27/24, for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and facility P&P review, the facility failed to ensure the facility's P&P for foods brought by family or visitors was followed when: * The facility failed to ensure the food items in the residents' refrigerator were labeled and dated as per the P&P. * The facility failed to discard foods by the use-by date. These failures had the potential to cause foodborne illnesses to the medically vulnerable resident population who consumed food brought from outside sources. Findings: Review of the facility's P&P titled Foods Brought by Family/Visitors revised 3/2022 showed food brought by family/visitors that is left with the resident to consume later is labeled and stored in a manner that it is clearly distinguishable from facility prepared food. Perishable foods are stored in re-sealable containers with tightly fitting lids in a refrigerator. Containers are labeled with the resident's name, the item and the use by date. The nursing staff will discard perishable foods on or before the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to ensure the medical records for two of two sampled residents (Residents 18 and 78) were accurate. * The facility failed to ensure Resident 78's closed record was complete and accurate. This failure had the potential to negatively impact the delivery of services as the medical information was inaccurate. * The facility failed to ensure a physician's signature was obtained on the POLST (Physician Orders for Life-Sustaining Treatment) for Resident 18. This failure had the potential to result in the residents' health wishes and directive not being honored. Findings: 1. Review of the facility's P&P titled Death of a Resident, Documenting revised 7/2017 showed appropriate documentation shall be made in the clinical record concerning the death of a resident. The name of the mortician and person removing the deceased resident must be entered in the resident's medical record. The person removing the deceased resident from the facility must sign the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the coordination of care between the facility and hospice provider for one of one final sampled resident reviewed for hospice services (Resident 28). * Resident 28's hospice monthly personalized visit schedules were incomplete. * Resident 28's hospice aide visit summaries were not completed and the facility failed to show the hospice aide had showered the resident twice per week. * The plan of care was not available or reviewed by the hospice staff. These failures posed the risk of the resident not receiving the care and services required to meet the resident's needs. Findings: Review of the facility's P&P titled Hospice Program revised 7/2017 showed it is the facilities responsibility to ensure the facility and the hospice collaborate on the coordination of care provided to the residents, to ensure quality of care for the residents receiving hospice services. The P&P also showed the most…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, facility document review, and facility P&P review, the facility failed to implement their Quality Assessment and Assurance plan of action. There was no documentation to show an evaluation of the facility's action plan to identify if the facility had achieved and sustained the improvement for the repeated deficient practices cited at F578, F684, F812, and F880 in accordance with their POC for the Recertification survey completed on 8/13/21. This failure had the potential to affect the quality of care for all the residents in the facility. Findings: Review of the facility's P&P titled Quality Assurance and Performance Improvement (QAPI) Program revised 2/20 showed on implementation, the QAPI plan describes the process for identifying and correcting quality deficiencies. Key components of this process includes among others: developing and implementing corrective action or performance improvement activities; and monitoring or evaluating the effectiveness of corrective action/performance improvement activities, and revising as needed. On 5/31/24 at 1323 hours, a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the infection control practices were maintained as evidenced by: * The facility failed to ensure two of two laundry dryers were free of noticeable buildup of lint. * The facility failed to ensure the staff performed the infection control practice before placing back the contaminated call light to Resident 3's bed. * The facility failed to ensure LVN 7 performed hand hygiene after picking up the black permanent marker on the floor. These failures had the potential to cause safety hazards and the spread infection to staff and residents. Findings: 1. Review of the facility's P&P titled Laundry Room Procedures (undated) showed drying clean linen includes keeping machines and lint traps clean. Review of the facility's P&P titled Laundry and Linen (undated) showed to maintain a clean and safe environment. On 5/29/24 at 1435 hours, a concurrent observation and interview was conducted with the Maintenance Director. Two of two Speed Queen Dryer machines…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary services and adequate supervision for one of two sampled residents (Resident 1) to prevent the elopement. * The facility failed to ensure the front door alarm was activated when no one was monitoring the front entrance, resulting in Resident 1 going out of the facility undetected. This failure had the potential to negatively impact the resident's well-being. Findings: Review of the facility's P&P titled Emergency Procedure - Missing Resident revised 8/2018 showed the residents at risk for wandering and/or elopement will be monitored, and the staff will take necessary precautions to ensure their safety. Medical record review for Resident 1 was initiated on 4/29/24. Resident 1 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Review of Resident 1's Change in Condition Evaluation dated 1/27/24, showed Resident 1 was found in the facility's parking lot walking around with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to implement their P&P to ensure the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for one of two sampled residents (Resident 1). * RN 1 failed to report Resident 1's allegation of abuse in a timely manner to the Administrator as per the facility's P&P when Resident 1 reported the alleged incident to RN 1 approximately oneweek prior. This failure led to the delay in the investigation of the alleged abuse, which had the potential for the staff to not take any necessary or appropriate corrective action timely to protect the residents. Findings: Review of the facility's P&P titled Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigating revised April 2021, under the section Reporting Allegations to the Administrator and Authorities, showed the following: 1. If resident abuse, neglect, exploitation, misappropriation of resident property…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.