Height Street Skilled Care

Based on interview and record review, the facility failed to ensure:1. The licensed nurses notified the physician in a timely manner when one of four sampled residents (Resident 1) had a change of condition.2. The licensed nurses failed to administer a medication as ordered by the physician for one of four sampled residents (Resident 1).These failures resulted in Resident 1 having abdominal pain and going to the hospital due to delay in care.Findings:During a review of Resident 1's Minimum Data Set (MDS - an assessment tool), dated 2/11/26, the MDS indicated, Resident 1 had a BIMS (Brief Interview for Mental Status) score of 8 (score of 8-12 means moderately impaired cognition).During a review of Resident 1's Change in Condition Evaluation (CCE), dated 2/21/26, the CCE indicated, CNA (Certified Nursing Assistant) informed CN (charge nurse) resident (1) has had 3 BMs (bowel movements) with diarrhea (passing loose, watery, or unformed stool three or more times in a single day) . Date and time of clinician notification: 02/21/2026 08:10. Recommendation of Primary Clinician(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 interview and record review, the facility failed to report an allegation of abuse for one of four sampled residents (Resident 1) within 24 hours. This failure resulted in delayed investigation of abuse and had the potential to place Resident 1 at risk for further abuse. Findings: During a review of Resident 1's admission Record (AR), dated 3/4/26, the AR indicated, DIAGNOSIS. UNSPECIFIED DEMENTIA (decline in mental ability such as memory, thinking or behavior that are severe enough to interfere with daily life) . ANXIETY (feeling of fear, dread, and uneasiness) . ALZHEIMER'S DISEASE (progressive, irreversible brain disorder that slowly destroy memory, thinking skills, and eventually the ability to perform simple tasks) . DEPRESSION (persistent feeling of sadness and loss of interest in activities) . COGNITIVE COMMUNICATION DEFICIT (difficulty with speaking, listening, reading, or writing caused by disrupted thinking skills) . NEED FOR ASSISTANCE WITH PERSONAL CARE.During a review of Resident 1's Minimum Data Set (MDS - an assessment tool), dated 12/4/25, the MDS indicated…

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 and record review, the facility failed to ensure two of three sampled residents (Resident 2 and Resident 3) were able to receive phone calls and outside confidential communication from services outside of the facility. This failure had the potential to violate Resident 2 and Resident 3's rights.Findings:During an interview on 12/18/25 at 3:45 p.m. with the Long-Term Care Ombudsman (LTCO), LTCO stated he has a hard time contacting residents at the facility by phone. LTCO stated at times the calls go unanswered and other times they will be sent to voicemail, he stated he cannot leave voicemail due to the nature of his work, he must keep communication confidential. LTCO stated on 10/31/25 he called the facility; the receptionist answered the call and then transferred the call to the nurses' station; the call went unanswered at the nurses' station and was delivered to voicemail. LTCO stated on 11/17/25 he called the facility three times, each time the receptionist would answer the call and then transferred the call to the nurses' station, the calls went unanswered 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 interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) received all their personal belongings upon discharge. This failure had the potential for Resident 2 to have missing items upon discharge.Findings: During a review of Resident 2's admission Record, (AR) the AR indicated, Resident 2 was admitted on [DATE] and discharged on 12/1/25. During a review of Resident 2's Inventory List, (IL) dated 11/6/2, the IL indicated Resident 2 had two grey t-shirts and one white sheet upon admission. During a concurrent interview and record review on 1/12/26 at 3:38 p.m. with Director of Nursing (DON), Resident 2's IL, dated 11/6/25 was reviewed. DON stated there was no evidence that Resident 2 received his belongings upon discharge on [DATE]. During a review of the facility's policy and procedure (P&P) titled, Theft Prevention, revised 11/1/17, the P&P indicated, The facility is committed to preventing the misappropriation of resident property. The facility will exercise…

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 and record review, the facility failed to provide a home medication list for one of three sampled residents (Resident 1). This failure had the potential for Resident 1 not to understand how and when to take his needed home medications. Findings: During an interview on 1/12/26 at 3:17 with Licensed Vocational Nurse (LVN) 1, LVN 1 stated upon discharge residents were provided with their medications, with a list of home medications with instruction on how to take the medication. LVN 1 stated the nurses educated the resident on the home medication list and instructions, once the education is completed, she has the resident sign the home medication list to prove the education was completed. During a concurrent interview and record review on 1/12/26 at 3:38 p.m. with Director of Nursing (DON), Resident 1's Discharge Instruction Form, (DIF) dated 12/8/25, was reviewed. The DIF, indicated, Resident 1's medications were provided at discharge, none were listed on Resident 1's DIF. The DIF, indicated See Attachment. DON confirmed no evidence Resident 1 received home…

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 record review, the facility failed to provide a sanitary environment for two of three residents (Resident 1 and Resident 2) when:Resident 1's bathroom had a foul smell. The bathroom tiles in three of four shower rooms used by Resident 2 and other residents were not cleaned.These failures had the potential for unpleasant experience for Resident 1 and Resident 2.Findings:1. During a concurrent observation and interview on 9/3/25 at 10:40 a.m. with Resident 1 in his room, Resident 1 was in his bed facing the bathroom. Resident 1 stated the bathroom had a strong foul and unpleasant smell. The bathroom smelled of urine and bleach like smell.During a concurrent observation and interview on 9/3/25 at 10:55 a.m. with Housekeeping Staff (HS), HS entered Resident 1's bathroom and stated the smell was not pleasant. HS stated another resident used to urinate on the floor in that bathroom and housekeeping was having a difficult time removing the urine odor.2. During an interview on 9/3/25…

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 record review, the facility failed to timely develop a baseline care plan with fall prevention interventions for two of three residents (Resident 1 and Resident 4) who were high risk for falls. This failure had the potential to place Resident 1 and Resident 4 at risk for falls and injury.Findings:During a review of Resident 1s admission Record (AD), undated, the AD indicated, Resident 4 was admitted on [DATE] with diagnoses including muscle weakness and abnormalities of gait and mobility.During a review of Resident 1's Assessment Outcomes Record (AOR), dated [DATE], the AOR indicated, Resident 1's fall risk assessment score of 60 (scores of 45 or higher indicate high fall risk).During a review of Resident 1's Care Plan Report (CPR), undated, the CRP indicated a fall prevention care plan was first created for Resident 1 on [DATE], 26 days after his admission.During a review of Resident 4's AD, undated, the AD indicated, Resident 4 was admitted on [DATE] and had diagnoses including…

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 record review, the facility failed to implement the fall prevention intervention of keeping the bed in the low position for one of three residents (Resident 4) who was high risk for falls. This failure had the potential to place Resident 4 at the risk for falls and injury.Findings:During a review of Resident 4's admission Record (AD), undated, the AD indicated, Resident 4 was admitted on [DATE] and had diagnoses including Alzheimer's disease (memory loss), muscle weakness, abnormalities of gait and mobility and pain.During a review of Resident 4's Assessment Outcomes Record (AOR), dated [DATE], the AOR indicated, Resident 4 had a fall risk assessment score of 50 (scores of 45 or higher indicate high fall risk).During a review of Resident 4's Care Plan Report (CPR), dated [DATE], the CRP indicated, The resident needs a safe environment with. the bed in the low position.During a concurrent observation and interview on [DATE] at 10:15 a.m. in Resident 4's room, with Family Member…

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 record review, the facility failed to manage the pain of one of three residents (Resident 4) when Resident 4 reported pain to Certified Nursing Assistant (CNA) A and CNA B but did not inform the Licensed Nurse (LN) C. This failure had the potential for Resident 4 suffering in pain.Findings:During a review of Resident 4's admission Record (AD), undated, the AD indicated Resident 4 was admitted on [DATE] and had diagnoses including Alzheimer's disease (memory loss), muscle weakness, abnormalities of gait and mobility, and pain.During a concurrent observation and interview on 9/3/25 at 10:15 a.m. in Resident 4's room, Resident 4 was lying in bed with Family Member (FM) 4 at bedside. FM 4 stated Resident 4 had dementia (memory loss) but was able make needs known.During an observation on 9/3/25 at 11:40 a.m. in Resident 4's room, CNA A and CNA B were providing care to Resident 4. During care, Resident 4 reported to CNA A and CNA B that he had pain in his arms. CNA A and CNA B left…

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 and record review, the facility failed to answer the call light timely for two of three sampled residents (Resident 1 and Resident 2). This failure had the potential for delay in care and needs not addressed promptly.Findings:During a review of Resident 1's Order Summary Report (OSR), dated 8/29/25, the OSR indicated Resident 1 had diagnoses of Hemiplegia and Hemiparesis (complete loss of muscle function) affecting left non-dominant side (weaker side of the body), Muscle Weakness, other abnormalities of gait (manner of walking) and mobility.During an interview on 8/28/25 at 1:20 p.m. with Resident 1, Resident 1 stated the night nurses were not supportive, they (night staff) didn't answer the call light. Resident 1 stated he felt ridiculed and helpless because the nurse had taken hours to answer his call light. Resident 1 stated he wanted his brief to be changed.During a review of Resident 1's BIMS (Brief Interview for Mental Status- cognitive assessment tool used to evaluate a resident's mental status), dated 7/25/25, the BIMS indicated Summary Score of 15 (score…

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 record review, the facility failed to implement the care plan (is a comprehensive, personalized document that outlines the specific needs of an individual requiring care, detailing the type of support, how it will be provided, and the goals of the care) for two of three sampled residents (Resident 1 and Resident 2) when: 1.Resident 1 was not repositioned every two hours. This failure had the potential for Resident 1 to develop pressure injury (localized damage to the skin and underlying soft tissue usually over a bony prominence). 2.Resident 2 was not supervised during a meal. This failure had the potential for Resident 2 not to consume the proper nutrition and had the potential for choking. Findings: 1.During a review of Resident 1's Care Plan (CP), dated 6/28/25, the CP indicated, [Resident 1] has altered skin integrity related to pressure injury/wound (localized damage to the skin and underlying soft tissue usually over a bony prominence) Contributory factors: admitted with pressure injury Re-opened pressure injury to sacrococcyx [end 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.

Based on interview and record review, the facility failed to notify the physician of a change in condition and administer medication according to the physician's order for one of three sampled residents (Resident 1) when Resident 1 was having continuous loose stools/diarrhea. This failure had the potential for Resident 1 losing three lbs. (pounds-weight measurement) weight in one week and potential for adverse health outcomes.Findings:During a review of Resident 1's Plan of Care (PC-is a comprehensive, personalized document that outlines the specific needs of an individual requiring care, detailing the type of support, how it will be provided, and the goals of the care), dated 6/13/25, the PC indicated, [Resident1] has dehydration or potential fluid deficit r/t (related to) new GT (gastrostomy tube feeding- where nutrition and/or fluids are delivered directly into the stomach through a tube inserted into the abdomen) feeding and GI infection (gastrointestinal infection - is an inflammation or irritation of the digestive tract, often caused by bacteria, viruses, or parasites.…

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 record review, the facility failed to ensure call lights were answered timely for three of six sampled residents (Resident 1, Resident 2, and Resident 3). This failure had to potential to negatively impact Resident 1, Resident 2, and Resident 3, physical and psychosocial health.Findings:During a review of Resident 1's Minimum Data Set, (MDS - an assessment tool) dated 7/18/25, the MDS indicated, Resident 1' s BIMS (Brief Interview for Mental Status-standardized assessment tool used to evaluate the mental processes that allow individuals to think, learn, and remember) score was 13 (13 to 15 points indicated the resident had cognitive intactness).During a concurrent observation and interview, on 7/30/25 at 12:01 p.m. with Resident 1, Resident 1 stated the best call light wait time was five minutes and the worst was 45 minutes. Resident 1 stated some staff will just walk by and not look at her. Resident 1 stated she calculates the wait time by looking at the clock observed…

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 record review, the facility failed to ensure two of six sampled residents (Resident 2 ad Resident 3) were treated with respect and dignity when Certified Nursing Assistants (CNA 1) entered Resident 2 and Resident 3's room singing at 4 a.m. This failure resulted in Resident 2 and Resident 3 being woken up and not to be treated with dignity and respect.Findings:During a review of Resident 2's Minimum Data Set, (MDS - an assessment tool) dated 6/11/25, the MDS indicated, Resident 1' s BIMS (Brief Interview for Mental Status-standardized assessment tool used to evaluate the mental processes that allow individuals to think, learn, and remember) score was 14 (13 to 15 points indicated the resident had cognitive intactness). During a review of Resident 3's Minimum Data Set, dated [DATE], the MDS indicated, Resident 3's BIMS score was 15. During a concurrent interview on 7/30/25 at 12:29 p.m. with Resident 2 and Resident 3, Resident 2 stated a female CNA comes in at 4 in the morning singing [NAME]…

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 and record review, the facility failed to follow their policy and procedure (P&P) on Assessment and Management of Resident Weights for one of five sampled residents (Resident 1) when the registered dietitian (RD)'s recommendations were not communicated to the physician. This failure had the potential to result in Resident 1's weight loss.Findings:During a review of Resident 1's admission Record (AR), dated 7/15/25, the AR indicated, Diagnosis. MILD PROTEIN-CALORIE MALNUTRITION (body has insufficient protein and energy to meet its basic needs).During a review of Resident 1's Weights and Vitals Summary (WVS), dated 7/15/25, the WVS indicated, Resident 1 weighed 126 lbs (pounds - unit of mass) on 6/24/25 and 119 lbs on 7/4/25 (lost seven lbs).During a review of Resident 1's Order Summary Report (OSR), dated 5/27/25, the OSR indicated, Resident 1's diet was no added salt.During a review of Resident 1's OSR, dated 6/11/25, the OSR indicated, Boost (nutritional supplement) . two times a day for Supplement.During a concurrent interview and record review on 7/15/25 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.

Based on interview and record review the facility failed to follow their policy and procedure on Controlled Medication Storage when:1. Licensed Vocational Nurse (LVN) 4, LVN 5, and LVN 6 did not immediately report the missing controlled narcotic medications (medications that are highly addictive and have a significant potential for abuse, classified as a controlled substance under the law, meaning its manufacture, distribution, and possession are regulated). 2. LVN 1 did not keep the discontinued 15 tablets of controlled narcotic medications in the medication cart to be counted every change of shift (changing from one work shift to another, e.g., from day shift to night shift).These failures resulted in missing narcotic medications, potential for narcotic diversion (getting legally prescribed narcotics into the wrong hands or using them for the wrong reasons), and had the potential to negatively impact resident's safety.Findings: 1.During an interview on 7/8/25 at 5:05 p.m. with Director of Nursing (DON), DON stated on 6/18/25 it was discovered that four oxycodone (narcotic pain…

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 and record review the facility failed to follow their policy and procedure on Unusual Occurrence Reporting when missing narcotic controlled medications (medications that are highly addictive and has a significant potential for abuse, classified as a controlled substance under the law, meaning its manufacture, distribution, and possession are regulated) was not reported to the California Department of Public Health (CDPH). This failure had the potential for narcotic diversion (the use and/or distribution not intended to) and had the potential for medication errors affecting residents' safety.During an interview on 7/8/25 at 5:05 p.m. with Director of Nursing (DON), DON stated on 6/18/25 it was discovered that four oxycodone (narcotic pain medication), four Percocet (narcotic pain medication), and four Norco (narcotic pain medication) were missing from the E-kit ( (emergency kit, containing a pre-determined supply of medications, especially controlled substances, for immediate patient needs during emergencies or when standard pharmacy services are…

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 and record review, the facility failed to: 1. Administer narcotic (a strong pain medication) medication according to the physician's orders for one of 10 sampled residents (Resident 1). 2. Reassess and re-evaluate the effectiveness of narcotic medication given for pain for one of 10 sampled residents (Resident 1).These failures had the potential for Resident 1 suffering from uncontrolled pain and/or result in adverse health outcomes. Findings:1. During a review of Resident 1's admission RECORD (AR), dated 7/9/25, the AR indicated, Resident 1 had diagnoses of Osteomyelitis (an infection of the bone), Complete traumatic amputation (complete removal of a body part due to accident or injury) of the left lower leg, Pain unspecified, Inguinal hernia (a bulge in the groin, area of the body located between the abdomen and the thigh, an area that can be painful). During a review of Resident 1's Order Summary Report (OSR), dated 6/2025, the OSR indicated, Norco (strong narcotic pain medication) 5-325 MG (milligram - a unit of measurement) Give one tablet by mouth every 12…

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 record review, the facility failed to ensure: 1. Three of three resident rooms (room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]) were clean and sanitary. This failure had the potential to spread infectious diseases to residents, staff, and visitors. 2. Environment had comfortable noise levels for two of two sampled residents (Resident 134 and Resident 31). This failure resulted in residents not getting rest and sleep. 3. One of 44 sampled resident (Resident 81) personal property was protected from theft and loss. This failure resulted in Resident 81's personal property not to be accounted for. Findings: 1. During an observation on [DATE] at 9:08 a.m. in room [ROOM NUMBER], the floor under the beds had thick debris and dusts like white particles. The room was occupied by two residents. Resident 24 was lying in bed with thick debris under his bed on the floor. The sliding door frame had thick dark colored debris. During an interview on [DATE] at 9:09 a.m. 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 observation, interview, and record review, the facility failed to ensure safe administration of medication for six of 16 sampled residents (Resident 46, Resident 183, Resident 23, Resident 47, Resident 7, and Resident 282) when medications were found at resident's bed side table. This failure had the potential for medications to be accessed by unauthorized staff and residents. Findings: a) During a concurrent observation and interview on 6/9/25 at 8:43 a.m. with Licensed Vocational Nurse (LVN) 4 in Resident 46's room, Resident 46 had zinc oxide (ointment used to treat and prevent diaper rash) 1 pouch of 8 ounces (oz) on bedside table. LVN 4 stated medication should not be left at bedside table. During a concurrent interview and record review on 6/10/25 at 2:38 p.m. with Registered Nurse (RN) 1, Resident 46's Self-Medication Administration Form (SMAF), dated 5/7/25 was reviewed. The SMAF indicated, Did the resident requested to self administer medication? indicated No Comments indicated Resident did not…

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 record review, the facility failed to ensure of one of 26 sampled milk glasses were at appropriate temperature. This failure had the potential to result in the residents having foodborne illness. Findings: During an observation on 6/11/25 at 11:15 a.m. in the kitchen, the milk temperature was at 46 degrees. During a concurrent observation and interview on 6/11/24 at 12:43 p.m. with Dietary Manager (DM) in the conference room, the test tray was delivered. DM tested the milk temperature and stated the milk was at 46 degrees. DM stated milk temperature should be below 41 degrees. During a review of the facility's policy and procedure (P&P) titled, Food Temperatures, dated 1/31/19, the P&P indicated, Acceptable Serving Temperatures Food Item Milk, juice < [less than] 41 [degree]. During a review of the facility's P&P titled, Food & Nutrition Services Policy and Procedure, Dated 12/1/21, the P&P indicated, 4. Milk may be poured into glass from the original container, covered, and returned to refrigeration. 5. Milk will not remain out 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.

Based on observation, interview, and record review, the facility failed to follow their policy and procedure (P&P) titled Dish Machine Temperature Recording, when dish machine's wash water was not at required temperature. This failure had the potential to result in unsanitary conditions of food utensils for foodservice safety and potential to place residents at risk for food borne illness. Findings: During a concurrent observation and interview on 6/11/24 at 8:33 a.m. with Dietary Aid (DA) 1 in the kitchen, the dishwasher was in use with dishes currently in the rack. The dishwasher already had a few cycles when the temperature of the dishwasher was reviewed. DA 1 stated the temperature was at 110 degrees. During a concurrent observation and interview on 6/11/24 at 11:31 a.m. with DA 2 in the kitchen, the dishwasher was in use with dishes currently on the rack. DA 2 stated the temperature was at 110 degrees. During a review of the facility's policy and procedure (P&P) titled, Dish Machine Temperature Recording, dated 6/1/17, the P&P indicated, Procedure II. Allow the dish machine to…

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 record review, the facility failed to ensure call light was answered timely for one of 32 sampled residents (Resident 134). This failure resulted in Resident 134 waiting for two hours with soiled brief which had the potential for skin breakdown and left Resident 134 feeling frustrated and depressed. Findings: During a concurrent observation and interview on 6/9/25 at 9:34 a.m. in Resident 134's room, with Resident 134, Resident 134 was lying in her bed with head of bed elevated. Resident 134 was alert and oriented. Resident 134 stated her call light was not answered and she had number two (pooped) waited two hours to be changed sometime last week in the night shift. Resident 134 stated she felt frustrated and depressed. Resident 134 stated she looked at her cell phone for time of how long her call light was not answered. During a review of Resident 134's Minimum Data Set (MDS-comprehensive assessment tool), dated 5/22/25, the MDS indicated Resident 134 was dependent (Helper does all of the effort) on toileting hygiene. The MDS indicated Resident…

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, and record review, the facility failed to follow their Policy and Procedure (P&P) titled, Room or Roommate Change for one of one sampled resident (Resident 56) when Resident 56 was not notified before he was moved to a different room. This failure resulted in disruption, confusion and making Resident 56 upset. Findings: During an interview on 6/11/25 at 3:56 p.m. with Resident 56, Resident 56 stated when he was admitted to the facility, he was put in a private room. Resident 56 stated a week later when he returned from a shower, staff were collecting his belongings and told him, We [staff] are moving you [Resident 56] to another room. Resident 56 stated he was not notified prior to this decision and didn't sign any type of acknowledgement. Resident 56 stated this (room change) made him upset. During a concurrent interview and record review on 6/12/25 at 8:58 a.m. with Social Services Director (SSD), SSD reviewed Resident 56's clinical record. SSD was unable to find documentation of Resident 56 was notified in writing of a room change. SSD stated he should have…

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 and record review, the facility failed to ensure the Advanced Beneficiary Notice of Non-coverage (ABN - a form that provides information to the beneficiary so that he/she can decide whether or not to get the care that may not be paid for by the Medicare and assume financial responsibility) was completed for two of three sampled residents (Resident 66 and Resident 183). This failure had the potential to negatively affect Resident 66 and Resident 183's finances. Findings: During a concurrent interview and record review on 6/11/25 at 12:18 p.m. with Business Office Manager (BOM), Resident 66's ABN, dated 4/22/25 was reviewed. The ABN indicated, Options: Check only one box. Option 1, Option 2, Option 3 the boxes were left blank. BOM stated the ABN was incomplete. During a concurrent interview and record review on 6/11/25 at 12:20 p.m. with BOM, Resident 183's ABN, dated 3/26/25 was reviewed. The ABN indicated, Options: Check only one box. Option 1, Option 2, Option 3 the boxes were left blank. BOM stated the ABN was incomplete. During a review of the facility's policy…

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 and record review, the facility failed to follow their policy and procedure (P&P) titled, Elder Abuse Prohibition and Prevention, when: 1. A thorough investigation of the resident-to-resident physical and verbal altercation for two of 44 sampled residents (Resident 16 and Resident 17) was completed. This failure had the potential for Resident 16 and Resident 17 not to be protected from further abuse. 2. A 5-day investigation report of the resident-to-resident physical and verbal altercation for two of 44 sampled residents (Resident 16 and Resident 17) was not submitted to the California Department of Public Health (CDPH) and the long-term care (LTC) ombudsman (advocate for the rights and well-being of residents in long-term care facilities). This failure had the potential for an incomplete investigation for Resident 16 and Resident 17. Findings: 1. During a concurrent interview and record review, on 6/10/25 at 2:32 p.m. with the Administrator, the Administrator stated the investigation was on the SOC 341 (Report of Suspected Dependent Adult/Elder Abuse). 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.

Based on interview, and record review, the facility failed to implement their policy and procedure (P & P) titled, Discharge Against Medical Advice (AMA), for one of one sampled resident (Resident 79). This failure had the potential to result in being discharged to unsafe conditions. Findings: During a review of Resident 79's Discharge Summary, (DS) dated 3/17/25, the DS indicated, Resident 79 was discharged AMA the next day. During an interview on 6/12/25 at 10:23 a.m. with Licensed Vocational Nurse (LVN 9), LVN 9 stated he had just given Resident 79 her medication when he last seen her at the facility. LVN 9 stated when he was done with the medication pass, he had noticed Resident 79 was not in her room. LVN 9 stated when he asked a staff member if they had seen her, the staff member stated she was in the lobby and had walked out the facility. LVN 9 stated Resident 79 did not inform him that she was unhappy with the care and did not mention anything about leaving the facility. During an interview on 6/12/25 at 11:06 a.m. with Director of Nursing (DON), the DON stated there was no…

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 and record review, the facility failed to notify the Ombudsman (advocate for the rights and well-being of residents in long-term care facilities) of transfer to hospital for one of one sampled residents (Resident 7). This failure had the potential for unsafe resident transfer and discharge. Findings: During a concurrent interview and record review on 6/11/25 at 9:42 a.m. with Director of Nursing (DON), Resident 7's Discharge Summary dated 2/26/25 and 7/31/24, were reviewed. The Discharge Summary indicated Resident 7 was transferred to the hospital on 2/26/25 and 7/31/24. DON stated there is no fax confirmation to prove that ombudsman notifications were completed. During a review of the facility's policy and procedure (P&P) titled, Transfer and Discharge, dated 9/1/23, the P&P indicated, A temporary transfer to an acute care facility is considered a Facility-intiated discharge and notice must be provided to the resident/resident representative as soon as practicable before the transfer. The Ombudsman must also be notified as soon as practicable.

Based on observation, interview, and record review, the facility failed to ensure care plan was implemented for one of three sampled residents (Resident 29). This failure had a potential for unintended weight loss for Resident 29. Findings: During a concurrent observation and interview on 6/9/25 at 10:18 a.m. with Resident 29 in Resident 29's room, Resident 29 stated all of his teeth were recently been extracted and was waiting for dentures. Resident 29 stated he had no teeth and was concerned about his weight loss. During a review of Resident 29's Minimum Data Set (MD'S-comprehensive assessment tool), dated 4/2/25, the MD'S indicated Resident 29's Brief Interview for Mental Status (BIMS - cognition assessment tool, 15-point scale: 13-15 cognitively intact) score was 13. During an interview on 6/11/25 at 3:47 p.m. with Licensed Vocational Nurse (LVN) 9, LVN 9 stated Resident 29 is not on the weekly weights for month of May or June, and his meal percentage is between the 50-75%. Resident 29 has lost one pound since the care plan was revised with no goal weight to see if he is really…

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 record review, the facility failed to: 1. Ensure medication was administered according to physician's order for one of five sampled residents (Resident 337). This failure had the potential to result in Resident 337 having adverse health outcomes. 2. Complete vital signs (temperature, heart rate, breathing rate, blood pressure, oxygen saturation [amount of oxygen in the blood], pain, and mental status) after seizure (sudden, uncontrolled electrical disturbance in the brain that can cause temporary changes in movement, awareness, or behavior) episodes for one of five sampled residents (Resident 85). This failure had the potential for Resident 85 to experience a delay in care due to an incomplete assessment. 3. Follow physician orders to have foot cradle (a device used to prevent blankets from touching the legs/feet) for one of eight sampled Residents (Resident 11). This failure had the potential for Resident 11 having worsening wound. Findings: 1. During a concurrent interview and record review on 6/11/25 at 8:30 a.m. with Licensed Vocational 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.

Based on observation, interview, and record review, the facility failed to provide oral care to one of six sampled residents (Resident 28). This failure had the potential to result in oral and dental issues. Findings: During an observation on 6/9/25 at 2:40 p.m. in Resident 28's room, Resident 28 was in bed smiling. Resident 28 had food particles in between teeth, teeth had brownish discoloration, and had few missing teeth. During an interview on 6/9/25 at 2:45 p.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated, It [Resident 28's teeth] looks like her teeth was not brushed for days. Resident 28 had contractures (hardening of joints and has limited movement) on both of her hands. During a review of Resident 28's Care Plan (CP) dated 1/29/25, the CP indicated, Oral Care: Provide setup with oral care and assist as indicated. During an interview on 6/12/25 at 10:32 a.m. with CNA 3, CNA 3 stated Resident 28 was sleeping and so teeth was not brushed. CNA stated, I did not go back to brush her teeth. During a review of the facility's policy and procedure (P&P) titled, Grooming…

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, and record review facility failed to implement their policy and procedure (P&P) titled, Pressure Ulcer Prevention, to prevent a pressure injury (skin damage that result of prolonged pressure or friction such as hips, buttocks, and heels) from occurring for one of five sampled residents (Resident 7). This failure resulted in Resident 7 developing a pressure injury on coccyx area (buttocks). Findings: During a concurrent interview and record review on 6/11/25 at 10:11 a.m. with Director of Nursing (DON), Weekly Summary (WS), dated 2/21/25 was reviewed. The WS indicated skin assessment section was blank. DON stated the WS had no skin assessment completed. DON stated skin assessment should be completed when weekly summary is being done. DON stated Resident 7 should be repositioned every two hours when resident is at risk for developing pressure wound. During an interview on 6/11/25 at 2:29 p.m. with Resident 7, Resident 7 stated, I went to the hospital because of the pressure sore in February 2025. Resident 7 stated she is not aware how pressure injuries occur.…

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 record review, the facility failed to failed to follow the physician's order to provide RNA (Restorative Nursing Assistant program-provide specialized care that helps residents regain or maintain their physical abilities and independence) program to one of six sampled residents (Resident 28). This failure had the potential for Resident 28 experiencing worsening immobility. Findings: During a concurrent observation and interview on 6/9/25 at 2:55 p.m. in Resident 28's room, Resident 28 was in bed, her both hands had contractures (hardening of joints, limited mobility). Resident 28 stated she has not been getting exercises and not has been out of bed in a while. During a review of resident 28's Order Summary Report (OSR), dated 5/12/25, the OSR indicated, RNA to perform AAROM [Active Assisted Range of Motion - type of exercise where a person moves a joint with the help of another person or a device, helps to build strength and flexibility in a recovering body part] Gentle…

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 record review, the facility failed to ensure safety for one of eight sampled residents (Resident 338) when smoking articles were left with the Resident 338 unattended. This failure had the potential to cause injury to residents residing in the facility. Findings: During a concurrent observation and interview on 6/10/25 at 9:18 a.m. with Certified Nursing Assistant (CNA) 12, a pack of cigarettes and a lighter were on Resident 338's bedside table. CNA 12 stated these smoking items are supposed to be locked up at the nurses' station and residents should not have access to them. During an interview on 6/10/25 at 9:30 a.m. with Director of Nursing (DON) and Resident 338, Resident 338 stated her cigarettes and lighter were in the purse sitting in her lap. DON stated to Resident 338 our policy that smoking articles are supposed to be locked up. During a review of Resident 338's Smoking Assessment (SA), dated 5/27/25, the SA indicated, Resident is a smoker and requires supervision. During a review of policy and procedure (P&P) titled, Smoking, 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.

Based on observation, interview, and record review, the facility failed to ensure a nephrostomy catheter (a tube placed through the skin into the kidney to drain urine when there's a blockage or other problem preventing normal drainage) collection bag was placed below the bladder for one of one sampled resident (Resident 28). This failure had the potential for bladder infection or leakage of the catheter bag. Findings: During a concurrent observation and interview on 6/9/25 at 3 p.m. in Resident 28's room, with Licensed Vocational Nurse (LVN) 7, Resident 28 was lying in bed on an upright position. Resident 28 had a nephrostomy catheter collection bag on the bed. The catheter bag had yellowish urine like liquid, placed beside her head, and higher than the level of her bladder. Resident 28 had contractures (hardening and deformity of joints, unable to move) on both of her hands, unable to lift or move objects. LVN 7 stated the catheter bag should be placed lower than the bladder. During a review of Resident's Care Plan (CP), dated 5/5/25, the CP indicated, [Resident 28] has…

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 record review, the facility failed to follow the physician's order to ensure one of five sampled resident's (Resident 337) pain medications were given according to the pain rate parameter. This failure had the potential for Resident 337 experiencing unrelieved pain. Findings: During a concurrent observation and interview on 6/11/25 at 8:30 a.m. with Resident 337 and Licensed Vocational Nurse (LVN) 6, in Resident 337's room. Resident 337 was moaning and stated she is having a pain rate of over 10 (pain rate of 10 means the worst possible pain). LVN 6 stated Resident 337 has an order for Tramadol (pain medication) for pain rate of 4-6 (for moderate pain). LVN 6 stated she will give the Tramadol. During a review of Resident 337's Medication Administration Record (MAR), dated June 2025, the MAR indicated, Tramadol Oral tablet 50 mg (milligram) Give 1 tablet by mouth every 12 hours as needed for pain - moderate (4-6). The MAR indicated Resident 337 was given Tramadol: a) On 6/5/25, with a pain rate of 7 (rate of 7-9 means severe pain). b) On 6/7/25,…

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 and record review the facility failed to ensure that discharge summary was completed for one of one sampled resident (Resident 7) when a discharge summary was missing skin assessment. This failure resulted in Resident 7's discharge summary incomplete documentation. Findings: During a concurrent interview and record review on 6/11/25 at 3:25 p.m. with Licensed Vocational Nurse (LVN) 5, Resident 7's Discharge Summary (DS), dated 2/26/25, was reviewed. The DS indicated skin assessment was blank. LVN 5 stated no skin assessment was completed on discharge summary. During a review of the facility's policy and procedure (P&P) titled, Transfer and Discharge, dated 9/1/23, the P&P indicated, Prior to discharging the resident, the Facility will prepare a Discharge Summary and will document the summary in the resident's medical record. At a minimum, the Discharge Summary will contain a summary of the resident's status, including a description of the resident's: i. Medically defined condition(s) and prior medical history.

Based on observation, interview, and record review, the facility failed to follow infection control standards of practice for one of 20 sampled residents (Resident 72) when staff didn't wear the proper Personal Protective Equipment (PPE-specialized equipment worn by staff to minimize exposure to infections or illness) when providing care. This failure had the potential to spread infectious diseases. Findings: During an observation and interview on 6/10/25 at 9:38 a.m. with Licensed Vocational Nurse (LVN) 5 in Resident 72's room, LVN 5 was providing wound care to Resident 72. LVN 5 did not wear a gown during the wound care. Resident 72 had signage above his bed indicating Enhanced Barrier Precautions- must wear a gown and gloves during any wound care requiring a dressing. LVN 5 stated, I realized it right afterwards, that I should had a gown on. During a review of the facility's policy and procedure (P&P) titled, Personal Protective Equipment, dated 7/1/23, the P&P indicated, I. Facility staff required to perform tasks that may involve exposure to blood/body fluids are provided 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.

Based on observation, interview, and record review, the facility failed to ensure one of three residents' rooms (Resident 24)'s was in good repair. This failure had the potential for affecting residents quality of life. Findings: During an observation on 6/9/25 at 9:08 a.m. in Resident 24's room, Resident 24 was lying in bed. There were three deep scrapes on the wall by the head of the bed. The scrapes were approximately 14 inches in diameter and half inch deep, 10 inches in diameter half inch deep scrape, and eight inches in diameter half inch deep scrape. There were thick debris on the floor. During an interview on 6/9/25 at 9:10 a.m. with Maintenance Supervisor (MS), MS stated the bed was hitting the wall. MS stated he was aware of the scrapes. MS stated, We do not fix it until there is penetration, meaning a hole to the next room. During a review of the facility's list of Maintenance Concerns (MC), dated 4/1/25 to 6/11/25, the MC indicated there was no report and no repair done on the scraped walls. During a review of the facility's policy and procedure (P&P) titled, Maintenance…

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 and record review the facility failed to complete an elopement risk evaluation to identify risk for elopement for one of three sampled residents (Resident 1). This failure resulted in Resident 1 eloping and potential for sustaining injuries. Findings: During a review of Resident 1's SBAR (Situation, Background, Assessment, and Recommendations - incident report), dated 3/24/25, the SBAR indicated, [at 1:50 p.m.] Resident [1] was found across the street from facility. Resident [1] repeatedly keeps stating, I need to get home. During a review of Resident 1's Elopement Evaluation (EE - elopement risk evaluation), dated 2/27/25, the EE indicated, 4. Has the Resident [1] verbally expressed the desire to go home, packed belongings to go home or stayed near an exit door was not marked with yes or no. The EE was incomplete and there was no indication of level of elopement risk of Resident 1. During a concurrent interview and record review on 3/27/25 at 3:51 p.m. with Registered Nurse (RN) 1, Resident 1's EE dated 2/27/25 was reviewed. Resident 1's EE indicated the question…

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 record review, the facility failed to follow the care plan to ensure call lights was within reach for one of three sampled residents (Resident 1) with a cognitive communication deficit (someone who has trouble communicating because of difficulties with thinking processes), when Resident 1 was left in the facility dining/activity room by herself without supervision and without the ability to call staff for help/assistance. This failure resulted in Resident 1 ' s injury to her left eye due to unknown causes and had the potential for negative health outcomes. Findings: During a review of Resident 1 ' s admission RECORD (AR), dated 3/7/25, the AR indicated, Resident 1 had a diagnoses including chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing), muscle wasting/atrophy (weakening, shrinking, and loss of muscle), cognitive communication deficit lack of coordination, muscle weakness, osteoarthritis (The cartilage [strong tissue that protects joints [the point where two things come together] and bones],…

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 record review, the facility failed to follow its own policy and procedure (P&P) when three of three sampled residents (Resident 1, Resident 2, and Resident 3) were not provided cigarettes during the scheduled smoking time. This resulted in Resident 1, Resident 2, and Resident 3 not being able to smoke and violated Resident 1, Resident 2, and Resident 3's rights. Findings: During a concurrent observation and interview on 2/11/25 at 12:30 p.m. with Resident 1, Resident 1 was in her room sitting in a wheelchair. Resident 1 stated all residents cigarettes were kept locked up and during smoking schedule, a designated staff member would go outside smoking area and hand out each resident's cigarette. Resident 1 stated on 2/10/25 at 3 p.m., she had gone outside for a smoke with Resident 3. Resident 1 stated, we waited and waited, and nobody came out to give us our cigarette. We waited probably more than an hour. During a concurrent observation and interview on 2/11/25 at 12:55 p.m. with Resident 2, Resident 2 was in bed lying down. Resident 2 stated he…

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 and record review, the facility failed to report an allegation of resident to resident altercation to CDPH (California Department of Public Health [state agency]) within 24 hours between two sampled residents (Resident 1 and Resident 2). This failure resulted in CDPH being unaware of the allegation, and had the potential to result in continual physical and psychosocial harm for both Resident 1 and Resident 2. Findings: During a review of Resident 1's MD/NP Progress Notes (MPN), dated 11/26/24, the MPN indicated, Writer was alerted to possible resident to resident altercation. Resident nurse stated that resident (Resident 1) had come to her and made an excited utterance stating that another resident had ' ran over' her foot and ' punched' her in the face twice. However, resident later denied that the other resident had made physical contact. Resident also indicated that they each started yelling at each other and commented that she had 4 brothers growing up so she ' knows how to swear like them.' During a review of Resident 2's MPN, dated 11/26/24, the MPN…

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 record review, the facility failed to implement their policy and procedure for Neurological Assessment (a series of tests and questions that assess the function of the brain, spinal cord, and nerves also known as neuro checks) for one of five sampled residents (Resident 1). This failure had the potential for adverse health outcomes. Findings: During a concurrent interview and record review on 11/20/24 at 12:15 p.m. with Director of Nursing (DON), Resident 1's Electronic Medical Record (EMR) dated 11/9/24 was reviewed. The EMR indicated Resident 1 was involved in a physical altercation with Resident 2. DON stated Resident 2 struck Resident 1 on her head resulting in Resident 1 obtaining a swollen lip and discoloration to the left side of her face from the head injury. DON reviewed the EMR for Resident 1 and stated neuro checks were not done. DON stated, Yes we missed that one (neuro checks for Resident 1). During a review of Resident 1's Minimum Data Set (MDS- an assessment tool) under the section BIMS (Brief Interview for Mental Status – an…

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 and record review, the facility failed to develop a plan of care for refusal of care for one of four sampled resident (Resident 1) when Resident 1 refused care for multiple times. This failure had the potential for the facility staff not addressing Resident 1 ' s needs and potential to result in adverse health outcomes. Findings: During a review of Resident 1 ' s Resident Daily Care Flowsheet (RDCF), the following were reviewed: a. On 3/7/23, the RDCF indicated, Refused to be change brief. b. On 3/16/23, the RDCF indicated, Resident [1] refused to changed. c. On 3/17/23, the RDCF indicated, Resident [1] refused to be brief change. d. On 3/21/23, the RDCF indicated, The resident [1] refused to be changed the diaper. e. On 3/23/23, the RDCF indicated, The resident [1] refused to take shower or bed bath. f. On 3/23/23, the RDCF indicated, The resident [1] refused to diaper change. g. On 4/09/23, the RDCF indicated, Resident [1] refused to change. h. On 4/10/23, the RDCF indicated, Resident [1] refused to be changed. i. On 4/13/23, the RDCF indicated, Resident [1]…

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 record review, the facility failed to address a change in condition for one of four sampled residents (Resident 1) when Resident 1 had a foul-smelling discharge and there was no documentation of change in condition, notification to physician of abnormal findings, and no documentation was provided by nurse. This failure had the potential for the facility staff not addressing Resident 1 ' s health care needs and potential to result in adverse health outcomes. Findings: During a review of Resident 1 ' s Resident Daily Care Flowsheet (RDCF), dated February 12, 2023, the RDCF indicated Resident [1] had foul smelling discharge from the front to the back of perineal [area between the vagina and anus in females] area. During a concurrent interview and record review on 9/19/24 at 8:35am with DON, DON reviewed Resident 1 ' s clinical record and was unable to find documentation or notification of the physician of Resident 1 ' s change in condition. DON stated, There is no document or progress/nursing notes on 2/12/23. I am not sure what happened on that day with the resident [1].…

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 and record review, the facility failed to ensure the facility ' s policy and procedure (P&P) on discharge of resident was followed for one of four sampled residents (Resident 1) when the facility did not make a follow up call to the acute hospital to determine the general status and condition of Resident 1. This failure had the potential to result in Resident 1 ' s suffering further injuries due to delay of care. Findings: During a review of Resident 1 ' s SBAR (Situation, Background, Assessment, Recommendations), dated 8/13/24, the SBAR indicated, Resident (1) slid from the shower chair while putting soap bar and shampoo away. Recommendations: Transfer to (acute hospital) s/p fall for further eval (evaluation) and tx (treatment). During an interview on 8/26/24 at 11:26 p.m. with Resident 1, Resident 1 stated, I pivoted myself over to the right close to the bed and I fell. I called for help and the nurse came in. They sent me to the hospital. I had a head injury and a tailbone injury. During a concurrent interview and record review on 8/29/24 at 3:30 p.m. 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 and record review, the facility failed to revise the fall care plan for one of three sampled residents (Resident 1) after a fall incident. This had the potential to place Resident 1 at risk for injury and harm. Findings: During an interview on 8/13/24 at 11:30 a.m. with Director of Nurses (DON), DON stated Resident 1 had three falls since being admitted on [DATE]. DON stated Resident 1 had fall incidents on 6/9/24, 7/31/24, and 8/7/24. During a concurrent interview and record review on 8/13/24 at 12:35 p.m. with DON, Resident 1 ' s fall care plan dated 7/31/24 was reviewed. DON confirmed Resident 1 ' s fall care plan dated 7/31/24 was not revised. DON stated there was no changes between 6/9/24 and 7/31/24 fall care plan. DON stated it was the facility practice to revised care plan after each fall incident. During a review of the facility ' s policy and procedure (P&P) titled Falls, dated 10/15, the P&P indicated, C. IDT will: 1. Create or revise care plan.

Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1) had fresh water available at bedside. This failure had the potential for Resident 1 not to receive the necessary hydration. Findings: During an observation on 7/31/24 at 9:29 a.m. in Resident 1's room, Resident 1's bedside table had two unopened straws and a white wrapper (no fluids or cup). During a concurrent observation and interview on 7/31/24 at 10:29 a.m. in Resident 1's room with Certified Nursing Assistant (CNA) 1, CNA 1 stated she is responsible for Resident 1 care today. CNA 1 confirmed there was no fluids at Resident 1's bedside table and stated Resident 1 gets thickened liquids (liquids made to move slower than thin liquids give the body more time to protect the air way, liquids can be thickened with powders or gels). During an interview on 7/31/24 at 11:26 a.m. with Dietary Supervisor (DS), DS stated residents with physician orders for thicken liquids were compiled on a list. During a review of the facility provide list titled, Breakfast Thickened…

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 record review, the facility failed to ensure two of four sampled residents (Resident 2 and Resident 3) had call light within easy reach. These failures had the potential for Resident 2 and Resident 3 not to be able to call for assistance and potential for unmet care needs. Findings: During an observation on 7/31/24 at 9:32 a.m. in Resident 2's room, Resident 2 was lying in bed with eyes closed. Resident 2's call light was observed on the floor (out of easy reach of resident). During a review of Resident 2' s Minimum Data Set, (MDS - an assessment tool) dated 7/27/24, the MDS indicated, Resident 2's BIMS (Brief Interview for Mental Status) score was 12 (a score of 8 to 12 suggests the resident has moderately impaired cognition). The MDS indicated Resident 2 needed setup and clean up assistance (helper sets up or cleans up; residents complete activity, helper assists only prior to or following the activity) for eating, substantial/maximal assistance (helper does more than half the effort) for toileting hygiene (the ability to maintain perineal…

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, record review, and facility policy review, the facility failed to follow physician's orders for pressure ulcer treatment for 1 (Resident #4) of 1 residents reviewed for pressure ulcers. Findings included: A facility policy titled, Medication Administration, dated 10/14/2015, specified, 2. Medications and treatments shall be administered as prescribed. The policy further specified, 16. Before administering medication or treatment, check every medication/treatment against physician's order and transcription in the Medication Administration or Treatment Record. Information on the label of each medication /treatment should match physician's order. An admission Record indicated the facility admitted Resident #4 on 02/15/2022. According to the admission Record, the resident had a medical history that included a diagnosis of Stage IV pressure ulcer of the sacral region (base of the spine). A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/13/2024, revealed Resident #4 had severe impairment in cognitive skills for daily…

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, record review, and facility document and policy review, the facility failed to ensure enhanced barrier precautions were provided for 1 (Resident #4) of 2 residents observed for infection control practices. Findings included: An undated facility policy titled, Standard and Enhanced Precautions revealed, V. Enhanced Standard Precautions A. Enhanced standard precautions will be implemented for residents with a known MDRO [multidrug-resistant organism] and who are at high-risk for colonization and transmission. B. Resident characteristics that are associated with a high-risk of MDRO colonization and transmission include: ii. Wounds or presence of pressure ulcer (unhealed). An undated facility document from the Centers for Disease Control and Prevention (CDC) titled, Enhanced Barrier Precautions revealed Providers and Staff must also: Wear gloves and a gown for the following High-Contact Resident Care Activities, which included Wound care: any skin opening requiring a dressing. An admission Record revealed the facility admitted Resident #4 on 02/15/2022.…

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 and record review, the facility failed to follow the physician ' s orders for one of four sampled residents (Resident 1). This failure had the potential for Resident 1 having adverse health outcomes. Findings: During a review of Resident 1 ' s Order Summary Report (OSR), dated April 2024, the OSR indicated, Lasix [medication for fluid retention] Oral Tablet 20 MG [milligram] Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION [high blood pressure] hold if SBP [Systolic Blood Pressure-measures the pressure in arteries when heart beats] <110 [below 110] and DBP [Diastolic Blood Pressure-measures the pressure in arteries when heart rests] <60 [below 60]. During a review of Resident 1 ' s Medication Administration Record (MAR), dated April 2024, the MAR indicated on 4/1/24, Lasix was administered with an SBP of 107. During a review of Resident 1 ' s OSR, dated April 2024, the OSR indicated, Metoprolol Tartrate [medication to treat high blood pressure] Tablet 25 MG Give 1 tablet by mouth two times a day related to ESSENTIAL (PRIMARY)…

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 record review the facility failed to implement their neurological assessment (an assessment that evaluates the brain and nervous system function) for one of three sampled residents (Resident 1). This failure had the potential for any abnormality of the brain and/or nervous system to go unnoticed, delayed appropriate treatment, and lead to negative consequences up to and including death. Findings: During an interview on 11/7/23 at 11:33 a.m. with Director of Nursing (DON), DON stated Resident 1 had a seizure (a sudden burst of electrical activity in the brain) on 10/24/23 which caused her to fall and fracture (break) her nose. DON stated Resident 1 had a secondary seizure attack on 11/1/23 that caused her to fall and lacerate (a deep cut or tear) on her forehead. During a concurrent observation and interview on 11/7/23 at 11:49 a.m. with Resident 1, in Resident 1's room, Resident 1 was lying in bed watching T.V. Resident 1 has a large gauze dressing to her forehead, mottled…

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 and record review, the facility failed to implement their policy on abuse for one of three sampled residents (Resident 1). This failure had the potential for abuse to continue and for other residents to potentially be abused. Findings: During an interview on 9/26/23 at 1:41 p.m. with Resident 1, Resident 1 stated he had issues with the way the facility Administrator in Training (AIT) had been treating him. Resident 1 stated a recent issue was when the AIT entered his room, removed a bag of items from atop of his closet and threw it on the floor. Resident 1 stated he made an official grievance to the facility regarding the AIT and had met with facility leadership. During a concurrent interview and record review on 9/27/23 at 11:35 a.m. with Social Services Director (SSD) , Resident 1 ' s INTERDISCIPLINARY TEAM CONFERENCE RECORD (IDTCR), dated 8/30/23 was reviewed. The IDTCR indicated, Meeting held to discuss concerns of the resident . Arrogance for violating the rights and privacy of the residents: Entering without knocking first and doing whatever he [AIT] wants…

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 record review, the facility failed to ensure one of four sampled residents' (Resident 2) call light button was within reach. This failure has the potential for Resident 2's needs not being attended to when she requires assistance. Findings: During a concurrent observation and interview on 8/3/23 at 2:45 p.m. in Resident 2's room, Resident 2 was sitting on her wheelchair and the call light button was on the other side of the bed. Resident 2 stated, she cannot reach her call light button and she would not know what to do if she needed assistance. During an interview on 8/3/23 at 2:48 p.m. with Director of Staff Development (DSD), DSD stated, the call light needs to be always within reach of Resident 2. DSD verified the finding. During an interview on 8/21/23 at 2:35 p.m. with Certified Nursing Assistant (CNA), CNA stated, she last checked on the resident (2) at around 1:30 p.m. CNA stated she forgot to place the call light button close to the resident [1]. During a review of Resident 2's Minimum Data Sets (MDS- comprehensive assessment tool), 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.