Kern River Transitional Care

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1.Ensure three of 32 sampled licensed vocational nurses (LVN 2, LVN 3, and TN 2) were competent (verified ability to perform skill) to perform care for one of one sampled resident (Resident 72) on dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly). 2. Ensure three of 32 sampled licensed vocational nurses (LVN 2, LVN 3, and treatment nurse [TN] 2) were competent to provide care for one of one sampled resident (Resident 36) with suprapubic catheter (a tube inserted into the bladder to drain urine). 3. Ensure two of 14 sampled registered nurses (RN 1 and RN 3) were competent to provide care for three of three sampled residents (Resident 96, Resident 437, and Resident 187) with on Midline Catheters (thin, soft tubing, placed into a vein to deliver medications directly into the bloodstream). 4. Ensure two of 14 sampled registered nurses (RN 1 and RN 3) were competent to provide care 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.

Based on observation, interview, and record review, the facility failed to follow and implement the Center for Disease Control and Prevention (CDC, nationally recognized health organization) infection control practices when: 1. Licensed Vocational Nurse (LVN) 2 did not follow Enhanced Barrier Precaution (EBP, precautions to reduce transmission of infectious organisms) protocols during closed contact with one of one sampled resident (Resident 72). 2. The X-ray Technician (XRT) stepped out of the room with contaminated gloves and isolation gown to answer a phone call after in close contact with one of one resident (Resident 96) on EBP. 3a. Treatment Nurse (TN) 1 threw the contaminated dressing with serosanguinous (thin, watery, and pinkish red in color fluid from a wound) drainage onto a regular trash bin. 3b. TN 1 did not perform hand hygiene before putting on a new pair of gloves. 3c. TN 1 used a pair of unsterile (free from germs) pair of scissors to cut the sterile not packing strip during wound packing for one of one sampled resident (Resident 96). 4. Central Supply Staff (CS) 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 that 108 out of 108 sampled Certified Nursing Assistants (CNAs) were attending at least 5 hours of dementia (a loss of mental function)-specific in-service training on an annual basis. This failure had the potential for CNAs to be uneducated how to meet care need of residents with dementia. Findings: During a concurrent interview and record review on 4/23/25 at 9:09 a.m. with Director of Staff Development (DSD), Dementia Mod [module] 4 (DM 4), dated 6/12/24 was reviewed. The DM 4 attendance sheet indicted 35 out of 108 CNAs attended dementia training. DSD stated only 35 CNAs attended the one-hour Dementia training. During a concurrent interview and record review on 4/23/25 at 9:11 a.m. with DSD, Dementia Review Annual (DRA), dated 8/23/24 were reviewed. The DRA attendance sheet indicated 60 out of 108 CNAs attended dementia training. DSD stated only 60 CNAs attended the one-hour training. During a concurrent interview and record review on 4/23/25 at 9:13 a.m. with DSD, DM 4 dated 9/19/24 was reviewed. The DM 4…

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 the facility failed to provide the completed Baseline Care Plan (BCP-initial instructions for care of the resident) Summary was provided to two of six sampled residents (Resident 72 and Resident 96) or the resident's responsible party within 48 hours of admission. This failure resulted in Resident 72 and Resident 96 or the resident's responsible party to be unaware of the plan of care during the first 48 hours. Findings: During a concurrent interview and record review on 4/23/25 at 9:44 a.m. with Director of Nursing (DON), Resident 72's admission Record (AR), was reviewed. The AR indicated Resident 72 was admitted on [DATE]. Resident 72's BCP dated 3/26/25 was reviewed. DON was unable to find documentation Resident 72's BCP summary was provided to the resident or the resident representative. DON was unable to provide documentation of Resident 72's signature or her responsible party (RP) signature indicating receipt of the BCP summary. DON stated she did not see a signed document 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 observation, interview, and record review, the facility failed to ensure : 1. Four of five sampled residents (Resident 132, Resident 35, Resident 437, Resident 34) medications were safely and securely stored from unauthorized personnel and other resident. This failure had the potential for medication to be accessed by unauthorized staff and residents. 2. The facility policy and procedure (P&P) titled, Disposal of Medications and Medication-Related Supplies, for one of one sampled controlled substance destruction record. This failure had the potential for drug diversion. Findings: 1a. During a concurrent observation and interview on 4/21/25 at 10:29 a.m. with Licensed Vocation Nurse (LVN) 1 Resident 132 had micronazole nitrate 2% (to treat itching and burning) was found on bedside table. There was no name on the bottle. Resident 132 stated this bottle is not mine. LVN 1 stated this medication should not be here. LVN 1 stated there is no name on the bottle. During a review of Resident 132's Order Summary Report (OSR), dated 3/2025, the OSR indicated Resident 132 had no order…

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 Social Services Director (SSD) met the required qualifications to manage and coordinate social services for 126 residents living in the facility and to fulfill the duties of the SSD. This failure had the potential to result in residents not being referred to appropriate social service agencies for their needs, required social services assessments performed and completed timely, accurate documentation and follow-up with residents and resident representatives of the residents' social service's needs, and ensure the residents could attain and maintain highest practicable physical, mental, or psychosocial well-being. Findings: During an interview on 4/23/24 at 10:23 a.m. with Social Services Director (SSD), SSD stated she was new to the facility. She stated her educational qualification included a Bachelor of Science Degree in Psychology, currently working on her master's in social work. SSD stated her work experience included social work in mental…

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's Quality Assurance and Performance Improvement (QAPI, process to identify problems and initiate improvement processes) committee failed to identify on-going issues, develop, and implement corrective action plans for Infection Prevention and Control practices (F636, F655, F656, and F868) and Social Services (F658, F790, F687, F842 and F623) not provided as identified by the survey team. These failures placed all 126 facility residents at risk for acquiring infectious diseases and not receiving medically necessary services. Findings: During a concurrent interview and record review on 4/24/25 at 3:09 p.m. with the Administrator, the minutes of the facility's QAPI (a committee that identifies quality deficits and implements corrective plans) meeting dated 4/18/25 and 1/19/25 were reviwed. The Administrator stated meetings were held every Tuesday to review new residents assessments. The facility's deficient practices reviewed included failure to assess each resident and care planning of residents. The Administrator stated…

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 Infection Preventionist (IP) attended two of three sampled Quality Assessment and Performance Improvement (QAPI, committee that identifies quality deficits and implements corrective plans) committee's meetings during 2024 and 2025. This failure had the potential for the facility to not be aware of infection control issues and develop a plan to address infection control issues. Findings: During a concurrent interview and record review on 4/24/25 at 3:09 p.m. with the Administrator, the QAPI committee sign in sheets dated 9/24/245, 1/19/25, and 4/18/25 were reviewed. The Administrator stated the IP attends the QAPI meetings. Administrator was unable to verify IPs attendance at the QAPI meetings on 9/24/245 and 4/18/25 with the QAPI attendance sheets. The Administrator stated the QAPI committee met September 2024, January 2025, and April 2025. The sign in sheet dated, 9/24/24 indicated the following signatures: Administrator, Director of Nursing (DON), Business Office Manager (BOM), Director of Staff…

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 follow their policy and procedure (P&P) titled, Personal Property when one of one sampled resident (Resident 55) personal belongings were not recorded on the inventory sheet upon admission. This failure resulted in the loss of Resident 55's personal belongings and the potential to result in difficulty replacing the personal belongings reported as lost. Findings: During an interview on 4/21/25 at 10:42 a.m. with Resident 55, Resident 55 stated she lost two sets of pajamas and a pair of pants approximately two months ago. Resident 55 stated she told the nurses and the nursing assistants about them. Resident 55 stated, I was told they are in the pile of resident clothing. They have not been returned or replaced. During an interview on 4/23/25 at 4 p.m. with Social Services Director (SSD), SSD stated she was not aware of Resident 55's lost personal belongings. SSD stated she had not been informed. SSD stated she had not personally visited and spoken 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 interview and record review, the facility failed to follow its policy and procedure (P&P) titled, Transfer or Discharge, Facility-Initiated, when the facility did not send a notice of transfer to the Ombudsman (representatives who assist residents in long-term care facilities with issues related to day-to-day care, health, safety and personal preferences) for one of six sampled resident's (Resident 40). This failure had the potential to result in Resident 40 not having an advocate who could inform them of their admission, transfer, and discharge rights and options. Findings: During a review of Resident 40's, Hospital Transfer Form (HTF), [undated], the HTF indicated, Resident 40 was transferred to the hospital on 3/6/25 and 3/10/25. There was no evidence of Ombudsman notification done on the hospital transfer. During a concurrent interview and record review on 4/24/25 at 2:59 p.m. with Social Services Director (SSD), Resident 40's HTF, dated 3/6/25 and 3/10/25, were reviewed. SSD stated the nurses were responsible to complete the notification to the Ombudsman. During 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 interview and record review, the facility failed to review and accurately complete the annual Pre-admission Screening Assessment and Resident Review (PASARR-federal requirement to help ensure that individuals are not incorrectly placed in nursing homes or long-term care instead of a psychiatric setting) for three of 16 sampled residents (Resident 10, Resident 115, Resident 109). This failure had the potential for residents to be placed in an inappropriate setting and not receive required services. Findings: During a concurrent interview and record review on 4/24/25 at 8:31 a.m. with Director of Nursing (DON), Resident 10's PASRR [PASARR] Level I Screening, dated 12/27/24 was reviewed. The PASRR indicated, Level I positive for SMI [Serious Mental Illness]/Positive for ID [Intellectual Disability]/DD [Developmental Disability]/RC [Related Condition]. DON stated Level I was completed on 12/27/24 and it was positive for Level I screening. DON stated there was no Level II PASRR completed on Resident 10. DON stated admission nurse start the PASRR and DON was informed, and it 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.

Based on observation, interview, and record review, the facility failed to develop and implement a person-centered care plan for four of four sampled residents (Resident 72, Resident 8, Resident 110 and Resident 13). This failure had the potential for unmet care needs. Findings: During an observation on 4/21/25 at 1:13 p.m. with Resident 72, in Resident 72's room, Resident 72's left foot's skin was dry and flaky, the left toes were red and swollen, the left great (big) toenail was long, thick, yellow-orange in color, brittle and crumbly. The left 2nd, 3rd, 4th, and 5th toenails were long and the nailbeds were yellow. The skin in between the toes was blackish in color with blackish debris. there was a small wound with a dried scab, below the 4th toenail and a small wound between the left 4th toe nail and the left 3rd toe. The right foot toenails were yellow, and the nails were long. The right big toe was swollen, the toenail was deformed, yellow, with ragged edges. The right 2nd toenail was long and yellow with crumbly edges. The skin in-between the right toes was blackish in color…

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 policy and procedure (P&P) titled, Guidelines for Preventing Intravenous [in the vein] Catheter [small flexible tube to deliver fluids or medications directly into the bloodstream]-Related Infections, for two of two residents (Resident 110 and Resident 13) when IVs were not flushed (rinsed out), changed, or removed as ordered. This failure had the potential for increased risk for infection. Findings: During a concurrent observation and interview on 4/21/25 at 1:19 p.m. with Resident 110, Resident 110 had an IV in the right wrist. Resident 110 stated her last dose of IV medication was three days ago. Resident 110 stated the IV had not been flushed since the last dose of medication was administered. During a concurrent interview and record review on 4/21/25 at 1:23 p.m. with Registered Nurse (RN) 1, Resident 110's Order Summary Report (OSR), dated 4/10/25 was reviewed. The OSR indicated insert peripheral (in arm) IV on 4/10/25. The OSR indicated, Change Peripheral IV site every 96 [4 days] hours 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 observation, interview, and record review, the facility failed to provide necessary service for personal and oral hygiene for two of two sampled residents (Resident 72 and Resident 133) who were dependent on care being provided. This failure resulted in Resident 72 had the potential for Resident 133 to acquire oral infection, further tooth decay. Findings: 1. During an observation on 4/21/25 at 1:13 p.m. with Resident 72, in Resident 72's room, Resident 72's left foot's skin was dry and flaky the right foot skin was dry. Resident 72's toenails were long and the nailbeds were discolored. The skin in between Resident 72's toes was blackish with blackish debris. During an interview on 4/21/25 at 3:40 p.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated Resident 72's nails were thick and orange in color. LVN 2 stated blackish colored dirt was in-between Resident 72's toes. During an interview on 4/21/25 at 4:02 p.m. with Treatment Nurse (TN) 2, TN 2 stated she saw Resident 72 this morning. TN 2 stated she checked if Resident 72 could wiggle her toes on the left foot. TN 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 record review, the facility failed to follow their policy and procedure (P&P) titled Activity Program, for one of 49 sampled residents (Resident 109) when activities of interest were not provided to Resident 109. This failure resulted in Resident 109 to experience a diminished quality of life due to not participating in either individual or group activities and the potential to result in depression (sustained loss of interest). Findings: During a concurrent observation and interview on 4/21/25 at 12:06 p.m. with Resident 109 in Resident 109's room, a Certified Nursing Assistant (CNA) delivered Resident 109's lunch tray. CNA described what was in front of him on his lunch tray. Resident 109 stated he was blind in his left eye and going blind in his right eye. Resident 109 stated the facility was not giving him anything to do but sit in bed. During a review of Resident's 109's admission Record (AR), dated 3/30/25, the AR indicated Resident 109 was admitted on [DATE] 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.

Based on observation, interview, and record review, the facility failed to follow the facility's policy and procedures (P&P) titled, Foot Care and Social Services when nursing assessments did not indicate foot skin or nail issues, foot care was not provided and a podiatry (treatment of foot disorders, ankle, and leg) referral was not completed for one of one sampled resident (Resident 72). This failure resulted in Resident 72's left toes to be red and swollen, skin dry and flaky, right and left feet toenails to be long, thick, hard, and yellow-orange, with blackish discoloration and debris in-between the toes. Findings: During an observation on 4/21/25 at 1:13 p.m. in Resident 72's room, both of Resident 72's feet had dry and flaky skin. The left toes were red and swollen, the left great (big) toenail was long, thick, discolored, brittle and crumbly. Resident 72's left 2nd, 3rd, 4th, and 5th toenails were long, and discolored. Two small wounds were on the left 3rd toe and 4th toe. Resident 72's right foot toenails were long and discolored. The right big toe was swollen. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure: 1. Licensed nurses were competent to assess and change suprapubic catheter (thin, flexible tube inserted directly into the bladder to drain urine) for one of one sampled resident (Resident 36). 2. The facility policy and procedure titled Suprapubic Catheter Care, met Society of Urologic Nurses and Associates (SUNA) Standards of Care. This failure had the potential to result in urinary tract infections, blockage, or leakage of urine, and other complications. Findings: 1. Director of Nursing (DON), DON stated Resident 36 came to the facility on [DATE] with a suprapubic catheter due to a neuromuscular dysfunction of the bladder (bladder function is interrupted due to damage or disease affecting the nerves and muscles that control urination). During a review of Resident 36's Physician's Order (PO), dated 6/11/24, the PO indicated, Change suprapubic catheter PRN (as needed) for dislodgement [out of position], malfunction [not working], and leakage.…

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 communication and coordination between the facility and dialysis (a procedure to remove waste products and excess fluids from the blood when the kidneys stop working) center was complete with assessment of the dialysis access site (surgically created access) on the Nursing Hemodialysis communication observation /assessment, for one of three sampled resident (Resident 79). This failure had the potential to result in complications due to having no assessment of the dialysis site. Findings: During a concurrent interview and record review on 4/26/25 at 4:25 p.m. with Licensed Vocational Nurse (LVN) 2, Resident 79's Hemodialysis Communication Observation/Assessment (Assessment), dated 3/26/25, 3/28/25, 4/9/25, 4/11/25, 4/16/25, and 4/21/25 were reviewed. The Assessment indicated post dialysis treatment was blank. LVN 2 stated if the dialysis center does not complete the form, the facility calls the dialysis center and get the post dialysis information. During a review of the facility's policy and procedure (P&P)…

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 assist one of one sampled resident (Resident 133) with a dental appointment. This failure had the potential for Resident 133 to acquire oral infections, further tooth decay, and gum diseases. Findings: During an observation and interview on 4/22/25 10:59 a.m. with Resident 133 in Resident 133's room, Resident 133's teeth were yellowish/gray. Resident 133 had multiple missing teeth. Resident 133 stated he had a lot of dental carries (cavities) and missing teeth. Resident 133 stated there was a cavity in his molar. Resident 133 stated, I need to be seen by a dentist badly. During a review of Resident 133's admission Record (AR), dated 4/4/25, the AR indicated the facility admitted Resident 133 on 4/4/25. During a review of Resident 133's Order Summary Report (OSR), dated 4/24/25 the OSR indicated on 4/4/25, the physician ordered Dental consult and treatment as indicated. During a review of Resident 133's IDT [Interdisciplinary Team)] Conference Summary [IDTCS], dated 4/16/25 (12 days after admission), 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 maintain a complete and accurate medical records for two of six sampled residents (Resident 72 and Resident 133) when: 1. One of one sampled resident's (Resident 72) Nursing Weekly Summary (NWS) did not accurately reflect the condition of the skin, toes, and toenail appearance. 2. One of one sampled resident's (Resident 72) Nursing Hemodialysis Communication Observation/Assessments were not completed on 3/27/25, 3/29/25, 4/3/25, 4/5/25, and 4/9/25. 3. One of one sampled resident's (Resident 133) Initial Social History Assessment was not completed. This failure had the potential to result in adverse consequences and lack of coordination and continuity of care. Findings: 1. During an observation on 4/21/25 at 1:13 p.m. in Resident 72's room, Resident 72's left foot had a short leg cast. Both of Resident 72's feet had dry and flaky skin. The left toes were red and swollen, the left great (big) toenail was long, thick, discolored, brittle and crumbly. Resident 72's left 2nd, 3rd, 4th, and 5th toenails were long, 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 interview and record review, the facility failed to follow its policy & procedure (P&P) titled Binding Arbitration Agreement (BAA, resolve disputes between healthcare providers and residents) for two of twenty sampled residents (Resident 337 and Resident 115) when admission Coordinator (AC), had Resident 337 and Resident 115 sign their BAA without understanding the legal implications. This failure resulted in Resident 337 and Resident 115 to not fully understand the legal document they signed. Findings: 1. During a concurrent interview and record review on 4/23/25 at 11:05 a.m. with AC, Resident 337's BAA dated 2/14/25 was reviewed. The BAA indicated, Resident 337 signed the BAA. Resident 337's clinical record (CR) was reviewed and indicated the following: A. Resident 337's Minimum Data Set (MDS - resident assessment tool), dated 1/31/25, the MDS indicated Resident 1 had a Brief Interview for Mental Status (BIMS, score of 9, a score of 0-7 means severe impairment, 8- 12 is moderate cognitive impairment,…

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, Care Plans, Comprehensive Person-Centered, for one of three sampled residents (Resident 1) when: 1. Care plan for refusal of care was not developed and implemented. This failure resulted in Resident 1 not receiving showers or baths for 13 days. 2. Respiratory Care plan was not developed and implemented. This failure had the potential for Resident 1's respiratory signs and symptoms to go unnoticed. Findings: 1. During a concurrent interview and record review on 2/25/25 at 3:01 p.m. with Director of Nursing (DON), Resident 1's Shower Sheets, dated 2/6/25, 2/10/25, 2/13/25, and 2/17/25 were reviewed. DON confirmed Resident 1 refused all showers and baths offered. Resident 1's care plans were reviewed. DON confirmed no care plan was developed or implemented for Resident 1's refusals for showers and baths. DON confirmed a refusal care plan should have been developed and implemented for Resident 1's refusals for showers and baths. 2. During a review of Resident 1's admission…

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 obtain physician's order and document the removal of midline intravenous catheter (midline IV - a thin, flexible tube inserted into a vein in the upper arm; used to administer medications, fluids, or draw blood over a longer period) for one of three sampled residents (Resident 1). These failures had the potential for Resident 1 to have retained piece of the catheter, blood loss and incomplete medical record. Findings: During a review of Resident 1's Medication Administration Record, (MAR) for February 2025, the MAR indicated Resident 1 was administered Meropenem (used to treat infections caused by bacteria) intravenous .every 6 hours for C-Diff (Clostridium difficile - a bacteria that cause inflammation of the large intestine) for 6 Days -Start Date-02/5/2025 1800 (6 pm). The MAR indicated Resident 1's last dose of meropenem was administered on 2/11/25 at 12pm. During a review of Resident 1's Infection Note, (IN) dated 2/12/25, the IN indicated, (Resident 1) is no longer on strict single room isolation . During a review 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 observation, interview, and record review, the facility failed to ensure care plans were consistently implemented for one of three sampled residents (Resident 1). This failure had the potential for Resident 1 to experience accidents and injuries. Findings: During a review of Resident 1's care plan with the focus on Resident 1 is at risk for falls ., revised 12/2/24 the care plan indicated red star program (an intervention put in place when a resident has two or more falls within 30 days, red stars should be placed on name plate outside the resident's room). During a concurrent observation, interview, and record review, on 12/31/24 at 11:20 a.m. outside of Resident 1's room, with Director of Nursing (DON). DON confirmed Resident 1 was attempting to get out of bed unassisted. Resident 1's care plan with the focus on risk for falls (12/2/24) was reviewed. DON confirmed Resident 1 was care planned for the red star program. DON confirmed Resident 1 did not have a red star on her name plate and stated Resident 1 should have a red star. During a review of the facility's policy 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 interview and record review, the facility failed to implement its own Fall Management policy and procedure (P&P) for one of six sampled residents (Resident 1). This failure resulted in an incomplete post fall assessment for Resident 1 and had the potential for unmet care needs. Findings: During an interview on 12/9/24 at 12:30 p.m. with Director of Nurses (DON), DON stated Resident 1 had a history of falling. DON stated Resident 1 had a fall incident on 11/28/24 in the bathroom and an unwitnessed fall incident on 12/2/24. DON stated Resident 1 was a high risk for falls. During a review of Resident 1' Post Fall Review (PFR) assessment dated [DATE], the assessment was noted to be incomplete. The PFR assessment did not indicate Resident 1's medications. During a concurrent interview on 12/9/24 at 1:30 p.m. with DON and Administrator, DON stated it was the facility policy to complete a PFR assessment after each fall. DON stated the PFR assessment included a review of the residents' medications, cognition,…

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, Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating, when suspicion of financial abuse was not reported to the attending physician (AP) for one of three sampled residents (Resident 1). This failure had the potential for Resident 1's AP not to be aware of the suspicion and the potential for emotional distress for Resident 1. Findings: During a concurrent interview and record review on 12/5/24 at 12:22 p.m. with Director of Nursing (DON) and Administrator. Administrator stated she took Resident 1 to the bank on 11/25/24, Resident 1 discovered there was money missing from his account. Resident 1's medical record was reviewed and there was no evidence the AP was notified of the suspicion of financial abuse. DON confirmed Resident 1's AP was not notified of the suspicion of financial abuse. Administrator stated No, I did not do that (report to Resident 1's AP). During a review of the facility's P&P titled, Abuse, Neglect, Exploitation or Misappropriation-…

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 report an allegation of sexual abuse for one of three sampled residents (Resident 1) within 24 hours to the California Department of Public Health (CDPH) and complete an investigation within five business days. This failure had the potential for Resident 1 experiencing continued sexual abuse. Findings: During a review of Resident 1's Progress Notes (PN), dated September 1, 2024, the PN indicated, In charge nurse informed that resident [1] stated that she was raped here some days ago by two men. During a concurrent observation and interview on 9/5/24 at 1:21 p.m. with Resident 1, Resident 1 was sitting in a wheelchair in the dining room, holding a color crayons in a basket with rabbit stuffed animal on her lap. Resident 1 stated, I was raped four times by two men since I have been here. It ' s [allegation of asexual abuse] in the records. Its listed here. I ' m afraid to be alone. During a concurrent interview and record review on 9/5/24 at 2:55 p.m. with the Director of Nursing (DON), Resident 1's clinical…

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 attending physician (AP) and responsible party (RP) and complete a change of condition (COC) for one of three sampled residents (Resident 1) when Resident 1 had two unwitnessed falls and COCs. This failure had the potential for Resident 1 ' s AP and RP to be unaware of Resident 1 ' s change of condition and had the potential for unmet care needs and treatments. Findings: During an interview on 8/22/24 at 1:03 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated the resident ' s AP and RP should be notified for any COC and complete a COC and document AP and RP notification. During a review of Resident 1 ' s Nurse ' s Note, (NN) dated 7/15/24, the NN indicated, (Resident 1) found sitting on the floor between his wheelchair and toilet. (Resident 1) stated he attempted toput (sic) himself back to his wheelchair from the toilet. No obvious injuries noted . nurse notified MD and family. During a review of Resident 1 ' s 72-hour Charting, (72HC) dated 7/22/24, the 72HC indicated, At 2:45 pm CNA called for 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 interview and record review, the facility failed to ensure the fall risk care plan was revised for one of three sampled residents (Resident 1). This failure had the potential for harm and injuries to Resident 1. Findings: During a review of Resident 1 ' s Fall Risk Observation/Assessment, (FROA) dated 5/19/24, the FROA indicated Resident 1 scored an 18 (a score of 16-42 indicate high risk for falls). During a review of Resident 1 ' s Nurse's Note, (NN) dated 7/15/24, the NN indicated, (Resident 1) found sitting on the floor between his wheelchair and toilet.(Resident 1) stated he attempted toput (sic) himself back to his wheelchair from the toilet. No obvious injuries noted. During a review of Resident 1 ' s 72-hour Charting, (72HC) dated 7/22/24, the 72HC indicated, At 2:45 pm CNA called for nurse ' s help to (Resident 1 ' s) room d/t (do to) (Resident 1) being on the floor. RN (registered nurse) was then called as well for initial assessment. (Resident 1) denies hitting his head. During a concurrent interview and record review on 8/22/24 at 1:47 p.m. with Director 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 ensure neurological checks (assessment of sensory and motor responses, especially reflexes, to determine whether the nervous system is impaired) were initiated and completed for one of three sampled residents (Resident 1) after Resident 1 had two unwitnessed falls. This failure had the potential for sign and symptoms of neurological deficits to go unrecognized for Resident 1 which had the potential for adverse outcomes. Findings: During an interview on 8/22/24 at 1:03 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated if the fall was unwitnessed, he would initiate neurological checks. LVN 1 stated Neurological check lasted for 72 hours. During a review of Resident 1 ' s Nurse ' s Note, (NN) dated 7/15/24, the NN indicated, (Resident 1) found sitting on the floor between his wheelchair and toilet. (Resident 1) stated he attempted toput (sic) himself back to his wheelchair from the toilet. No obvious injuries noted . During a review of Resident 1 ' s 72-hour Charting, (72HC) dated 7/22/24, the 72HC indicated, At 2:45…

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 follow its own policy and procedure (P&P) titled, Documentation Accuracy In The Health Record, for one of three sampled residents (Resident 1). This failure resulted in Resident 1 ' s medical record to be inaccurate. Findings: During a concurrent interview and record review on 8/22/24 at 1:47 p.m. with Director of Nursing (DON), Resident 1 ' s admission Record, (AR) was reviewed and indicated Resident 1 was admitted on [DATE]. DON confirmed Resident 1 ' s AR indicated Resident 1 ' s emergency contact (EC) was his wife. Resident 1 had no other responsible party or EC listed. Resident 1 ' s Discharge Summary, (DS) dated 8/1/24 was reviewed. DON confirmed the DS indicated, I have read, understand and received a copy of this discharge summary: IV. Resident/Responsible Party/Date: (Resident 2 ' s name) V. Relationship to resident/date self . DON confirmed Resident 2 was a resident in the facility and not in any way affiliated with Resident 1. During a review…

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 one of three sampled residents (Resident 1) grievances were addressed and resolved. This failure resulted in violation of resident's rights to have Resident 1 grievance addressed. Findings: During an interview on 8/2/24 at 2:27 p.m. with Social Service Director (SSD), SSD stated whenever the resident or family member had concerns or grievances, the social services would give them the Grievances Interview Record (GIR) to fill out or social services would fill the GIR out for the resident or family member. SSD will then give the GIR to the department responsible for the grievance. The facility would try to resolve the grievance within five days. SSD will contact the resident or family member to inform them of the resolution or SSD will set up a care conference depending on the situation. During a review of Resident 1's GIR, dated 8/25/23, the GIR indicated, (Resident 1) was told by CNA (Certified Nursing Assistant) when asking for help to the bathroom you show [sic] know better then [sic] to call us during shift…

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 a change in condition was communicated to the primary care physician for one of four sampled residents (Resident 1). This failure had the potential to result in Resident 1's overall condition to worsen due to delay of care. Findings: During a review of Resident 1's Admission/readmission Evaluation/Assessment (AREA), dated 7/15/24, the AREA indicated, Resident alert and oriented x 4 [alert and oriented to person, place, time and situation]. During a review of Resident 1's Baseline Care Plan Person-Centered Care Planning (BCP), dated 7/15/25, the BCP indicated Resident 1 was alert and cognitively intact. During a review of Resident 1's PN, dated 7/18/24, the PN indicated, Resident is alert with some confusion noted. The PN indicated no documentation of the facility notifying the primary care physician about Resident 1's new onset of confusion. During a review of Resident 1's Minimum Data Set (MDS [an assessment tool]), dated 7/19/24, the MDS indicated Resident 1 had a BIMS (Brief Interview of Mental Status) of 6 (0-7…

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 notify the physician of a change of condition for one of three sampled residents (Resident 1). This failure had the potential for Resident 1 not having his care needs met. Findings: During a concurrent interview and record review on 7/23/24 at 2:50 p.m. with DON, Nursing-Daily Skilled Charting Form-V 3.0 (NDCF) , dated 5/25/2024 was reviewed. The NDCF indicated a blood pressure (BP - the pressure of circulating blood against the walls of blood vessels) of 184/82 (normal blood pressure is when systolic pressure of less than 120 and a diastolic pressure of less than 80). DON reviewed Resident 1's clinical records and stated there is no documentation that Resident 1 was re-assessed or if physician was notified for the high blood pressure. DON stated anything over 160 should be reported to physician. During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, dated February 2021, the P&P indicated, Our…

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 and implement a comprehensive person focused care plan for one of three sampled residents (Resident 1) when Resident 1 was non-compliant with the use of call light. This failure placed Resident 1 at risk for not having his care needs met. Findings: During a review of Nurse ' s Note (NN), dated 5/26/24, the NN indicated, Resident [1] noted to be non-compliant to call light. Use of call light explained to resident [1] within each interaction. Still non-compliant to call light and yelling at staff when needing assistance at this time. During a concurrent interview and record review on 7/9/24 at 10 a.m. with Assisted Director of Nursing (ADON), Resident 1 ' s Care Plan, dated 5/16/24-5/27/24 was reviewed. ADON reviewed Resident 1's Care Plan and stated there should ' ve been a care plan in place for a non-compliance with the use of call light. During an interview on 7/9/24 at 11:30 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 was very non-compliant with using his call light. Staff would always…

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 communication and coordination between the facility and dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working) center was complete with assessments of the dialysis access site (surgically created access) on the Pre (before) and Post (after) Dialysis Communication Form (PDCF) for one of two sampled residents (Resident 1). This failure had the potential to result in complications due to having no assessment of the dialysis site. Findings: During a concurrent interview and record review on 7/23/24 at 2 p.m. with Director of Nursing (DON), Resident 1's Pre and Post-Dialysis Communication Form (PDCF) dated 5/17/24, 5/20/24 and 5/22/24 was reviewed. The PDCF indicated post -Dialysis Assessment was blank on 5/17/24, 5/20/24 and 5/22/24. DON stated the post dialysis was not completed and it (PDCF) should be completed once Resident 1 is back in the facility. During a review of the facility's policy and procedure (P&P) titled, Hemodialysis Catheters-Access and Care…

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 its policy and procedure titled Care Plans, Comprehensive Person-Centered, for one of two sampled residents (Resident 1). This failure has the potential for accidents and injuries. Findings: During a review of Resident 1's SBAR (situation, background, assessment, and recommendation) Communication Form dated 6/8/24 at 10 p.m., the SBAR indicated Resident 1 had an unwitnessed fall. slid off bed. found lying supine (face up) on the floor by right side of bed. Resident 1's post Fall Risk Observation/Assessment indicated Resident 1 was a high risk for fall. Resident 1's fall care plan was not updated after the fall incident on 6/8/24. During a concurrent interview and record review on 7/16/24 at 12:35 p.m. with Assistant Director of Nurses (ADON), ADON reviewed Resident 1's SBAR dated 6/8/24 at 10 p.m. and ADON confirmed Resident had an unwitnessed fall incident on 6/8/24. ADON was unable to find an updated fall care plan for Resident 1. ADON stated Resident 1's care plan should have been updated after the fall incident…

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 sampled residents (Resident 1)'s call light was within easy reach. This failure had the potential for Resident 1's activities of daily living need not being met. Findings: During a concurrent observation and interview on 6/24/24 at 2:30 p.m. with Certified Nursing Assistant (CNA) 1, in Resident 1's room, Resident 1's call light button was on the floor and was not in Resident 1's reach. CNA 1 stated, Call light is on the floor, and it should be in Resident 1's reach. During a concurrent observation and interview on 6/24/24 at 3 p.m. with Licensed Vocational Nurse (LVN) 1, in Resident 1's room, Resident 1's call light button was on the floor and was not in Resident 1's reach. LVN 1 stated, Call light was not in Resident 1's reach, and it should be clipped to sheet or to resident's clothes so it can be in reach. During a review of Resident 1's Care Plan (CP) , dated 2024, the CP indicated, ADL [Activity of Daily Living]/Mobility: [Resident 1] has actual ADL/mobility decline and requires…

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 monitor and document behavioral episodes for one of three sampled residents (Resident 1). This failure had the potential for untreated Resident 1's worsening behavior. Findings: During an observation on 6/28/2024 at 10:10 a.m., outside of conference room, Resident 1 was sitting in his wheelchair. Resident 1 was agitated (restless) and upset. During a review of Resident 1 ' s Care Plan (CP), dated 6/20/2024, the CP indicated, Psychosocial behavior: exhibits or is at risk for behavioral symptoms (i.e., striking out, grabbing others, combative, verbally, or physically abusive, inappropriate disrobing, smears/throws food/feces/objects due to bipolar disorder [mood disorder]. Goal: will accept supportive strategies and demonstrate adequate control of emotions which will not result in injury to self or others. Interventions/Tasks: Document and record behavioral episodes. During a concurrent interview and record review 7/25/2024 at 3:13 p.m. with Director of Nursing (DON), DON reviewed Resident 1's CP and was unable…

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 when medications were not documented immediately after being administered for two of three sampled residents (Resident 1 and Resident 2). This failure resulted in inaccurate medical records. Findings: During a review of Resident 1's Medication Admin (administration) Audit Report (MAAR) dated 6/26/24, the MAAR indicated, Resident 1 was to receive Atorvastatin Calcium (medication used to treat high cholesterol) .Schedule Date.6/9/24 2100 (9 p.m.).Administered 6/9/24 2258 (10:58 p.m.).Doxycycline Hyclate (antibiotic used to treat infection).Schedule Date.6/9/2024 2100 (9 p.m.).Administration Time 6/9/24 2258 (10:58 p.m.).Humalog (medication used to treat high blood sugar).Administration Time 6/9/24 2100.Administered 6/10/24 2:10 a.m. During a review of Resident 2's MAAR dated 6/26/24, the MAAR indicated, Resident 2 was to receive Empagliflozin (medication to treat high blood sugar).Schedule Date.6/24/24 9:00 a.m.Administration Time.18:35 (6:35 p.m.).Empagliflozin.Schedule Date.6/25/24 9:00…

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 the medication carts and medication room were free from expired medications. This failure had the potential for residents to receive expired medications and have adverse health outcomes. 2. Follow their policy and procedure (P&P) on medication labeling. This failure had the potential to result in medication errors. 3. Ensure an insulin (medication used to manage blood sugar levels) was dated. This failure had the potential for residents to receive insulin with decreased potency (strength of medication required to produce an effect). Findings: 1. During a concurrent observation and interview on 5/15/24 at 10:03 a.m. with Director of Nursing (DON), in the medication room C, there was a box of emergency drug supply. The form on the box titled, Refrigerated Emergency Drug Supply had a kit expiration date of 1/31/24. DON verified the refrigerated emergency drug supply was expired and stated the expired refrigerated emergency drug supply box should not be in the refrigerator. During a concurrent…

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 maintain dignity for two of 57 sampled Residents (Resident 389 and Resident 84) when: 1. Resident 389 was dressed in donated clothing due to a delay in washing her personal clothing. 2. Resident 84's oral hygiene was not maintained. These failures had the potential to negatively affect Resident 389 and Resident 84's psychosocial wellbeing and Resident 84's dental health. Findings: 1. During a concurrent observation and interview on 5/13/24 at 11:45 a.m. with Resident 389's family member (FM) 1 in Resident 389's room, Resident 389 was in bed wearing a white undershirt with a plaid button up shirt and blue jeans. Resident 389 stated she did not have her own clothes to wear. One item of clothing was in her drawer and 2 jackets in her closet. Resident 389 stated she did not like the way the clothes she was wearing felt and did not like to wear someone else's clothes. Resident 389 stated the clothes were too big and not comfortable. Resident 389 demonstrated how big the jean pants were around her waist. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a physician order (PO) was obtained and Self-Administration of Medication Assessment ([NAME]) was completed for one of one sampled resident (Resident 40). This failure had the potential for unsafe and inappropriate self-administration of medication. Findings: During a concurrent observation and interview on 5/13/24 at 10:32 a.m. with Resident 40, in Resident 40's room, one bottle multivitamins was found on Resident 40's bedside table. Resident 40 stated he takes the mutltivitamins on the bedside table two times daily. During a concurrent interview and record review on 5/13/24 at 10:42 a.m. with Assistant Director of Nursing (ADON), Resident 40's POs and assessments were reviewed. ADON was unable to provide PO or [NAME] for the use of the multivitamin found on Resident 40's bedside table. ADON stated Resident 40 should have had a PO and a [NAME] to ensure Resident 40 was safe to self-administer the medications. During a review 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 ensure one of 57 sampled residents (Resident 134) was notified of a room change. This failure had the potential for Resident 134, Resident 134's family and Medical Doctor (MD) not to be informed of reason for room change. Findings: During a concurrent interview and record review on 5/13/24 at 4:19 p.m. with Director of Nursing (DON), DON reviewed Resident 134's medical record and confirmed Resident 134's room was changed on 4/22/24. DON reviewed Resident 134's Notice of Room Change, (NRC) dated 4/22/24. DON confirmed the NRC was blank (no indication for the room changes, no notification to family, or MD). During a review of the facility's policy and procedure (P&P) titled, Room Change/Roommate Assignment, revised May 2017, the P&P indicated, 2. Unless medically necessary or for the safety and well-being of the resident (s), a resident will be provided with an advance notice of the room change. Such notice will include the reason(s) why the move is recommended.6. Documentation of a room change is recorded in the resident'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, and record review, the facility failed to ensure one of 57 sampled residents (Resident 41), was provided a homelike environment. This failure had the potential to negatively effect Resident 41's mental wellbeing. Findings: During a concurrent observation and interview on 5/14/24 at 11:10 a.m. with Resident 41, in Resident 41's room, Resident 41 in his wheelchair with legs extended straight out in front of him. The corner where two walls met, next to Resident 41's bed, was damaged. The damaged area was approximately four feet high and four feet wide, with scraped, chipped, and missing patches of drywall, exposed metal edges, mesh material and holes. Resident 41 stated he ran into the wall with his wheelchair almost everyday and it had not been repaired since he lived there. Resident 41 stated he would like the wall damage to be repaired because it was his home. During a review of Resident 41's electronic medical record (EMR), the EMR indicated Resident 41 had lived in the room since 10/18/23. During an interview on 5/15/24 at 9:18 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.

Based on interview and record review, the facility failed to update the Quarterly Minimum Data Set (MDS-resident assessment tool) Comprehensive Assessment (QMDSCA) for one of one sampled resident (Resident 48) with a new mental disorder diagnosis. This failure had the potential to inaccurately reflect Resident 48's clinical status and result in an inaccurate plan of care. Findings: During a review of Resident 48's Nursing Home Visit (NHV), dated 2/12/24, the NHV indicated, Chief Complaint. Patient is seen for psychiatric evaluation at the request of primary care physician to assess the patient's behaviors and review of any psychotropic medications [medications that affect mind, emotions, and behavior]. Assessment. Post-traumatic stress disorder [PTSD-mental health condition triggered by a traumatic event]. Diagnosis attached to this encounter . Post-traumatic stress disorder. During a concurrent interview and record review on 5/15/24 at 2:11 p.m. with Minimum Data Set Nurse Assistant (MDSNA), Resident 48's Psychotropic IDT [PIDT - Interdisciplinary Team-multiple health care…

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 three sampled residents (Resident 36 and Resident 48) had a new Level I Preadmission and Resident Review (PASRR-screening tool used to determine specialized mental health services). This failure resulted in Resident 36 and Resident 48 not receiving recommendations for specialized services to best meet their needs. Findings: During a review of Resident 36's admission Record (AR), dated 5/14/24, the AR indicated, Resident 36 was admitted on [DATE]. A diagnosis of Schizoaffective Disorder, Bipolar Type [mental disorder affecting a person's ability to behave and think clearly] was added 6/15/22. During a concurrent interview and record review on 5/15/24 at 9:06 a.m. with Director of Nursing (DON), Resident 36's PASRR Level I Screening, dated 4/19/22 was reviewed. The PASRR Level I Screening indicated, Resident 36 did not have a diagnosis of mental illness. DON stated Resident 36 did have a mental illness, but facility was not aware at 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.

The facility failed to submit a Pre-admission Screening and Resident Review (PASRR-screening tool used to determine specialized mental health services) Level I screening prior to admission for one of one sampled resident (Resident 48). This failure had the potential for Resident 48 to not receive mental health services. Findings: During a concurrent interview and record review on 5/15/24 at 9:19 a.m. with Director of Nursing (DON), Resident 48's Preadmission Screening and Resident Review [PASRR] Level I Screening, dated 8/16/23 was reviewed. DON stated this was Resident 48's most recent screening after she was readmitted from the hospital. During an interview on 5/15/24 at 11:28 a.m. with DON, DON stated Resident 48 should have had two Level I PASRR screenings, one on admission 6/2/23 and another one on 8/16/23 when she was readmitted from the hospital. DON stated the PASRR on admission 6/2/23 was not done and should have been. During a review of the facility's policy and procedure (P&P) titled, admission Criteria-PASRR, dated March 2019, the P&P indicated, 9. All new admissions 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.

Based on interview and record review, the facility failed to update the comprehensive care plan for one of one sample resident (Resident 48) when a new mental health condition was diagnosed. This failure had the potential to negatively impact care. Findings: During a review of Resident 48's, Nursing Home Visit (NHV), dated 2/12/24, the NHV indicated, Chief Complaint. Patient is seen for psychiatric evaluation at the request of primary care physician to assess the patient's behaviors and review of any psychotropic medications [medications that affect mind, emotions, and behavior]. Assessment. Post-traumatic stress disorder (PTSD- a mental health condition triggered by a traumatic event) . Diagnosis attached to this encounter .Post-traumatic stress disorder. During a concurrent interview and record review on 5/15/24 at 9:48 a.m. with Director of Nursing (DON), Resident 48's care plans were reviewed. The facility was unable to provide a care plan for the mental health diagnosis of PTSD. The DON stated resident should have had a care plan for PTSD. During a concurrent interview 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.

Based on interview and record review, the facility failed to ensure: 1. Staff followed the facility's policy and procedure (P&P) titled, Medication Administration for one of one sampled resident (Resident 134) when the first dose of Lorazepam (medication used to treat anxiety) was not administered until 21 hours after the physician order (PO). This failure had the potential for Resident 134 to suffer unnecessary agitation. 2. Staff followed the facility's P&P, titled Enteral [external] Tube Medication Administration for one of two sampled residents (Resident 18) with a Gastrostomy tube (G-tube, tube inserted directly into the stomach for nutrition and medication]. This failure had the potential to place Resident 18 at risk for not receiving physician ordered medication or nutrition. Findings: 1. During a review of Resident 134's Medication Administration Record, dated March 2024, the MAR indicated: Lorazepam Concentrate 2MG [milligrams- unit of measure]/ML [milliliter- unit of measure] give 0.25 ml sublingually [under the tongue] two times a day for Agitation -Start Date- 04/28/2024…

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 carry out fall prevention interventions identified in the care plan for a resident at high risk for falls when the bed was left in a high position on two occasions for one of one sampled resident (Resident 78). This failure had the potential for Resident 78 to fall and become injured. Findings: During a concurrent observation and interview on 5/13/24 at 10:13 a.m. with Certified Nursing Assistant (CNA) 1 in Resident 78's room, Resident 78 was in bed with bed in a high position. CNA 1 stated the bed should have been down low because Resident 78 is at risk for falls. During a concurrent observation and interview on 5/14/24 at 9:07 a.m. with CNA 1 in Resident 78's room, Resident 78 was in bed with bed in a high position. CNA 1 stated the bed should not have been left that high. During a concurrent interview and record review on 5/16/24 at 8:08 a.m. with Director of Nursing (DON), Resident 78's Fall Risk Observation/Assessment (FROA), dated 4/10/24 and Care Plan (CP), dated 7/18/23 were reviewed. The FROA…

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 care for an indwelling catheter (tube placed into the bladder to drain urine) to prevent infections and other complications for one of 13 sampled residents (Resident 25). This failure had the potential to result in infections and injury to the penis or bladder. Findings: During a concurrent observation and interview on 5/13/24 at 12:15 p.m. with Certified Nursing Assistant (CNA) 2 in the B wing dining room, Resident 25 was sitting in a wheelchair with the indwelling catheter bag (urine collection bag) and tubing touching the floor under the wheelchair. CNA 2 stated it should not have been on the floor because it could have gotten pulled out or caused an infection. CNA 2 pushed Resident 25 to his room with the catheter bag dragging under the wheelchair. During an interview on 5/13/24 at 12:28 p.m. with Director of Nursing (DON), DON stated the urinary drainage bag should have been kept off the floor. During a review of the facility's policy and procedure (P&P) titled, Catheter Care, Urinary, 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 follow their policy and procedure (P&P) titled, Food For Residents From Outside Sources for one of one sampled resident (Resident 40) when Resident 40's coffee creamer was not dated when opened or stored in the refrigerator. This failure had the potential to cause foodborne illness. Findings: During an observation on 5/13/24 at 10:32 a.m. in Resident 40's room, there was a half empty bottle of coffee creamer on Resident 40's bedside table with no open date. During a concurrent observation and interview on 5/14/24 at 9:07 a.m. with Certified Nursing Assistant (CNA) 1 in Resident 40's room, the half empty bottle of coffee creamer with no date was still on the bedside table. CNA 1 stated Resident 40 did not like to let them take it. CNA 1 stated the label on the bottle of coffee creamer indicated it should be refrigerated and discarded after 14 days. CNA 1 stated the bottle does not have an open date so there was no way to tell how long it had been there. During a concurrent interview and record review on…

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 maintain an accurate medical record (MR) for one of 57sampled residents (Resident 48) when: 1. A mental health diagnosis of Post Traumatic Stress Disorder (PTSD- a mental health condition triggered by a traumatic event) was not added to Resident 48's diagnoses list. 2. A mental health diagnosis of psychosis (symptoms include confused thinking, false beliefs, and hallucinations [hearing, seeing, smelling, or tasting something that is not there]) was dropped from Resident 48's diagnoses list. These failures resulted in an incomplete and inaccurate medical record and had the potential to impact patent care. Findings: 1. During a concurrent interview and record review on 5/15/24 at 9:37 a.m. with Director of Nursing (DON), Resident 48's active diagnoses were reviewed. The active diagnoses indicated no diagnosis for PTSD. DON stated PTSD was not on the diagnosis list and should have been added. During a concurrent interview and record review on 5/15/24 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 observation, interview, and record review, the facility failed to implement infection control practices when: 1. One of one resident's (Resident 64) wheelchair was not clean or safe for use. 2. Housekeeping staff did not follow transmission-based precautions (TBP - guidelines for use of personal protective equipment when caring for resident with a contagious infection) for one of one sampled resident (Resident 85). 3. Water Management Program (WMP) did not assess risk, identify areas of concern, monitor and identify measures to prevent growth of opportunistic waterborne pathogens (germs that grow well in water) within the facility's water system for all residents, staff, and visitors. 4. Maintenance and cleaning of one of one resident's (Resident 125) resident owned C-Pap (continuous positive airway pressure - medical equipment used to assist breathing during sleep) machine was not completed and documented. These failures had the potential to result in increased risk of infection, serious illness or death of the facility's residents, staff, and visitors. Findings: 1. 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 interview and record review, the facility failed to follow its policy and procedure on Bowel Management Protocol for one of three sampled residents (Resident 1). This failure had the potential for Resident 1 to suffer pain and discomfort. Findings: During an interview on 3/21/24 at 2:38 p.m. with Licensed Vocational Nurse (LVN 1), LVN 1 stated bowel protocol will be initiated for a resident who has not had a bowel movement (BM) for 48 hours or 72 hours. LVN 1 stated she would administer MOM (milk of magnesia- used to treat constipation) if ineffective, the next day she would administer suppository or enema. LVN 1 stated if a resident refuses bowel protocol, I notify MD [medical doctor] and document the resident's refusal. During a review of Resident 1's Medication Administration Record, (MAR) for March 2024, the MAR indicated the following: Milk of Magnesia [MOM-medication used to treat constipation] . 400MG (milligrams- unit of measure)/5ML(milliliter- unit of measure) . Give 30 ml by mouth every 24 hours as needed for BM Protocol # 1 Give if resident has no BM for 3 days.…

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 a bed hold (holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization) was offered to one of three sampled residents (Resident 1). This failure had the potential for Resident 1 and Resident 1's Representative to be unaware for the facility's bed hold policy. Findings: During a review of Resident 1's SBAR (situation, background, appearance, and review) Communication Form, dated 3/3/24, the SBAR indicated Resident 1 was sent to the hospital for altered mental status with aggression. During an interview on 3/25/24 at 8:12 a.m. with Resident 1's Representative (RR), RR stated the facility did not offer Resident 1 a seven-day bed hold (3/3/24). During an interview on 3/28/24 at 10:48 a.m. with Business Development and Admissions (BDA), BDA stated when a resident is transferred out to the hospital, and they have Medi-Cal (type of medical insurance) we hold a bed for seven days. BDA stated any other insurance, the facility admission agreement indicated 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 ensure one of four sampled residents (Resident 1) treatments were administered and documented as ordered. This failure had the potential for infection and worsening of Resident 1 ' s wounds and skin conditions. Findings: During a review of Resident 1 ' s Weekly Summary Notes, (WSN) dated 2/19/24, the WSN indicated, [Resident 1] is alert and oriented, able to make needs known. During an interview on 3/1/24 at 11:02 a.m. with Resident 1, Resident1 stated he had a sore on his buttocks. Resident 1 stated he gets daily wound care, but he did not get any wound care this weekend (2/24/24 and 2/25/24). During a concurrent interview and record review on 3/1/24 at 2:20 p.m. with Assistant Director of Nursing (ADON), ADON reviewed Resident 1 ' s Treatment Administration Record, (TAR) for February 2024. ADON confirmed the following: Cleanse stage 3 [full thickness loss of skin] pressure injury [localized damage to the skin and or underlying soft tissue usually over a bony prominence] to coccyx [tailbone] with NS [normal saline-salt…

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 three of nine sampled resident (Resident 1 Resident 2, and Resident 3) attending physician (AP) and resident ' s representative (RR) were notified of alleged abuse. This failure had the potential for Resident 1, Resident 2, and Resident 3 ' s AP and RP not to be aware of the alleged abuse. Findings: During a review of the Resident 1's Investigation regarding alleged physical abuse with [Resident 1], dated 2/5/24, the investigation indicated, On 1/31/24 at approximately 6:00 am [Resident 1] reported [Resident 2] . entered [Resident 1 ' s] room and hit [Resident 1] on the head three times with a book. During a review of the Resident 3's Investigation regarding alleged verbal altercation with [Resident 3], dated 1/23/24, the investigation indicated, On 1/18/24 at approximately 5:30 am [Resident 3] . it was reported that [Resident 3 ' s] sitter was verbally threatening towards [Resident 3] . During an interview on 2/13/24, at 1:37 p.m. with Licensed Vocational Nurse (LVN 1), LVN 1 stated, if there was an allegation or…

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 call light was answered timely for one of five sampled residents (Resident 1). This failure had the potential to result in unmet care needs, and negatively impact safety, physical, mental, and psychosocial well-being for Resident 1. Findings: During a review of Resident 1 ' s Minimum Data Set, (MDS - an assessment tool) dated 11/15/23, the MDS indicated, Resident 1 ' s BIMS (Brief Interview for Mental Status) score was 12 (a score of 8 to 12 suggests the resident has moderately impaired cognition) During a concurrent observation and interview on 12/6/23 at 3:03 p.m. with Resident 1, in Resident 1 ' s room. Resident 1 stated call lights take 20 to 30 minutes to be answered. Resident 1 stated 30 minutes most of the time. Resident 1 stated she watch the clock; a clock was observed on the wall. Resident 1 stated she need assist to go to rest room. Resident 1 stated, It [the wait] makes her feel frustrated and angry. During a review of Resident 1 ' s MDS, dated 11/15/23, the MDS indicated Resident 1's Functional…

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 medications administered were documented for one of four sampled resident (Resident 2). This failure had the potential for medication error and had the potential for adverse outcome. Findings: During an interview on 12/6/23 at 4:11 p.m. with Licensed Vocational Nurse (LVN 1), LVN 1 stated she documents in the medications she administers in the residents ' Medication Administration Record, (MAR) right after the medications are administered. During a concurrent interview and record review on 12/6/23 at 4:31 p.m. with Director of Nursing (DON), Resident 2 ' s MAR, dated November 2023 was reviewed. DON confirmed the following: Hydrocodone Bitartrate [medication used to help relieve severe ongoing pain] ER [extended release- slowly released into the body over a period of time, usually 12 or 24 hours.] Capsule Extended Release 12 Hour 20 MG [milligram-unit of measure] Give 1 capsule by mouth every 6 hours for Pain -Start Date- 05/20/2022 1800 [6 p.m.] -D/C [discontinued] Date- 11/21/2023 0725 [7:25 a.m.] On 11/6/23 at 6…

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 sufficient nursing staff to meet the daily needs for one of four sampled resident (Resident 1) This failure had the potential to result in unmet care needs, and negatively impact safety, physical, mental, and psychosocial well-being for Resident 1. Findings: During a concurrent observation and interview on 12/6/23 at 3:03 p.m. with Resident 1, in Resident 1 ' s room. Resident 1 stated call lights take 20 to 30 minutes to be answered. Resident 1 stated 30 minutes most of the time. Resident 1 stated she watch the clock; a clock was observed on the wall. Resident 1 stated she need assist to go to rest room. Resident 1 stated, It [the wait] makes her feel frustrated and angry. During a review of Resident 1's Minimum Data Set, (MDS - an assessment tool) dated 11/15/23, the MDS indicated, Resident 1's BIMS (Brief Interview for Mental Status) score was 12 (a score of 8 to 12 suggests the resident has moderately impaired cognition). During an interview on 12/6/23 at 3:19 p.m. with Certified Nursing Assistant (CNA 1), CNA 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 medical record was accurate for one of four sampled residents (Resident 3). This failure had the potential for Resident 3 to receive inappropriate treatments. Findings: During an interview on 11/30/23 at 9:40 a.m. with Family Member (FM 1), FM 1 stated Resident 3 ' s medical record (MR) was inaccurate. FM 1 stated Resident 3 was never diagnosed with type 2 diabetes [DM- a problem in the way the body regulates and uses sugar as a fuel] . FM 1 stated Resident 3 was taking a medication normally prescribed for DM called Farxiga [is a medication used to treat type 2 diabetes. It is also used to treat adults with heart failure and chronic kidney disease] but Resident 3 was prescribed Farxiga off label for heart failure [a chronic condition in which the heart does not pump blood as well as it should]. During a review of Resident 3 ' s [Hospital Record] Rounds Report (RR), dated November 14, 2023, the RR indicated, Asthma [a condition in which your airways narrow and swell and may produce extra mucus], Chronic…

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 one of four sampled resident's (Resident 2) quality care when the facility failed to implement the care plan for one Resident 1. This failure had the potential to affect Resident 2's physical and psychosocial well-being. Findings: During a review of Resident 1's care plan with the focus on episodes of physical aggression towards another resident [Resident 3], initiated on 11/10/23, the care plan interventions included Resident 1 would be placed with a one-to-one sitter. During a review of Resident 2's Nurse's Note, (NN) dated 11/11/23, the NN indicated Resident 2 stated One lady [Resident 1] came in my room and pulling string of my call light and slapped to left side of my face. He said he's not able to move to defend himself from her. During a review of Resident 1's NN dated 11/11/23, the NN indicated, Resident 1 was found in Resident 2's room. Resident 2 accused Resident 1 of hitting and yelling at Resident 2. The NN indicated Resident 1 was placed back in the care of her one-to-one sitter. During an interview on…

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 staff member worked within scope of practice and maintained current and active certification or licensure. This failure resulted in unqualified staff administering and interpreting test results and had the potential for the facility ' s staff and residents to be exposed to a potentially serious infectious bacterial disease. Findings: During an interview and record review on 11/29/23 at 12:05 p.m. with Director of Staff Development (DSD), DSD stated tuberculosis (TB-potentially serious infectious bacterial disease that mainly affects the lungs) test were given annually and upon hire. DSD stated on the day of orientation the employee is injected with tuberculin (substance made from tubercle bacilli administered just under the surface of the skin; used in testing for TB infection), and they return in two to three two to three days to have the test read. DSD stated the test results are read by either herself or a nurse. DSD stated she, the Infection Preventionist or the Staffing Coordinator (SC) will administer 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: 1. Ensure all facility staff were trained on reporting abuse according to its policy and procedure (P&P) titled Abuse, Neglect, Exploitation, and Misappropriation – Reporting and investigating. This failure had the potential to result in residents abuse not reported. 2. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral problems according to its P & P titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program. This failure had the potential for residents to be vulnerable to further abuse. Findings: 1. During an interview on 9/29/23, at 12:40 p.m. with Licensed Vocational Nurse (LVN 1), LVN 1 stated, her responsibilities for allegation or suspected abuse were to investigate, complete a full body assessment, notify the resident's physician (MD) responsible party (RP), call the Director of Nursing (DON), and Abuse Coordinator (AC), initiate 72-hour monitoring, and care plans. During an interview on 10/10/23, at 11:03 a.m. with LVN 3, LVN 3…

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: 1.Report a suspicion of abuse for one of 10 sampled residents (Resident 1). 2.Report an allegation of abuse timely for one of 10 sampled residents (Resident 2). 3. Report a suspicion and allegation of abuse for one of 10 residents (Resident 3). These failures resulted in delayed investigation of abuse for Resident 2 and Resident 3 as well as had the potential for Resident 1, Resident 2 and Resident 3 to be at risk for further abuse. Findings: 1.During an interview on 9/29/23, at 1:19 p.m. with Director of Nursing (DON), DON stated, she did not report suspected abuse to California Department of Public Health (CDPH) or Ombudsman because the facility reported to the local police department (LPD) as Resident 1 attacking Hospitality Aide 1 (HA 1). During a review of Resident 1's BIMS (Brief Interview for Mental Status- an assessment tool for cognition), dated 7/19/23, the BIMS indicated, Resident 1 had a score of 5 (a score of 0-7 points…

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. Report investigation timely for one of ten sampled resident (Resident 2). 2.Investigate suspicion of abuse for one of ten sampled residents (Resident 1) 3. Thoroughly investigate allegations of abuse for one of ten sampled residents (Resident 2). 4. Screen four of eleven sampled direct care staff prior to hire. 5.Provide evidence of abuse training for one of eleven sampled direct care staff during new hire orientation. These failures had the potential to result in further abuse, abuse to go unnoticed, not reported, not investigated due to untrained staff for Resident 1, Resident 2, and all residents in this facility. Findings: 1. During a concurrent interview and record review on 10/23/23 at 12:10 p.m. with Assistant Director of Nursing (ADON), ADON reviewed Resident 2's Progress Noted, (PN) dated 9/29/23. ADON confirmed Resident 2's PN indicated an allegation of abuse was reported to Director of Nursing (DON). ADON confirmed allegation of abuse was reported on 10/10/23 (11 days after allegations were made). ADON…

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 a care plan for one of nine sampled residents (Resident 2). This failure had the potential for physical and psychosocial change in Resident 2 to go unnoticed. Findings: During a concurrent interview and record review on 10/23/23, at 12:10 p.m. with Assistant Director of Nursing (ADON), ADON reviewed Resident 2's Care Plan (CP) with the focus on risk for emotional distress/late onset symptoms of injury related to allegations of abuse, initiated 9/29/23. The CP indicated one of the interventions were Monitor QD [every day] for s/s [signs and symptoms] emotional distress, late onset symptoms of physical injuries x [for] 72 hours . ADON reviewed Resident 2's medical record and confirmed Resident 2's monitoring was not completed. ADON stated the facility should implement and complete the interventions put in place. During a review of the facility policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised March 2022, The P&P indicated. A comprehensive, person-centered care plan should include…

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 develop and implement comprehensive care plans for three of 59 sampled residents (Resident 98, Resident 108, Resident 216) when: 1. Resident 216 had a indwelling urinary catheter (IUC-tube placed in bladder to drain urine). 2. Resident 216 used a Trilogy machine (device used to help breathe). 3. Resident 98 had wounds. 4. Resident 108 was diagnosed with depression. These failures had the potential to result in staff being unaware of residents' needs. Findings: 1. During an observation on 5/10/21, at 11:40 AM, in Resident 216's room, Resident 216 had an IUC tubing connected to a urinary drainage bag in place. During a review of Resident 216's Order Summary Report (OSR - Physician's Order), dated 4/17/21, the OSR indicated, Foley catheter (IUC) care every shift . May change urinary drainage bag as needed and per facility protocol. During a concurrent interview and record review, on 5/13/21, at 9:25 AM, with Director of Nursing (DON),…

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 1. Based on observation, interview, and record review, the facility failed to prevent the unintended weight loss for two of 59 sampled residents (Resident 92 and Resident 216) when: 1a. A care plan addressing weight loss was not developed and implemented for Resident 92. 1b. The nursing staff did not notify the Registered Dietician Nutritionist (RDN), Primary Care Physician (PCP), and the Responsible Party (RP) 1 of Resident 92's weight loss. 1c. Ensure the Interdisciplinary Team (IDT - a group of healthcare professionals who work together to provide the greatest benefit for the residents) analyzed the significant weight loss for Resident 92. 1d. RDN did not conduct a follow up evaluation when Resident 92's weight loss was noted. 1e. Facility did not notify the PCP and RP of Resident 216's weight loss. These failures had the potential to result in Resident 92 and Resident 216's unplanned total weight and did not allow RP's participation in the plan of care. 2. Based on observation, interview, and record review,…

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 9 of 9 nursing staff (Certified Nursing Assistant (CNA) 1, CNA 2, Licensed Vocational Nurse (LVN) 2, LVN 3, Registered Nurse (RN) 1, RN 4, Restorative Nursing Assistant (RNA) 1, RNA 2, and RNA 3) completed required annual competencies/training. These failures had the potential for residents not to receive care in a safe and competent manner. Findings: During an interview on 5/11/21, at 10:17 AM, with CNA 2, CNA 2 stated, she has not had an annual competency. During an interview on 5/11/21, at 12:07 PM, with RNA 1, RNA 1 stated she did not get an annual competency or training. During an interview on 5/12/21, at 1:52 PM, with LVN 2, LVN 2 stated, she has not had any competency or skills checklist since her orientation. During a concurrent interview and personnel file review on 5/12/21, at 7:53 AM, with the Director of Staff Development (DSD), DSD verified, no annual competencies were completed for the following employees: CNA 2, date of hire 10/26/18 CNA 3, date of hire 8/20/19 LVN 2, date of hire 3/11/19 LVN 3 , date…

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 and interview, the facility failed to ensure five of five confidential residents (Resident 400, Resident 401, Resident 402, Resident 403, Resident 404), were served palatable meals. This failure had the potential to result in decreased appetite, and adequate nutrition. Findings: During a group interview on 5/11/21, at 9 AM, with Resident 400, Resident 401, Resident 402, Resident 403, and Resident 404, they stated, they were consistently unhappy with the food served by the facility. Three of the five stated the food was not served at the correct temperatures. Two of the five stated they felt the staff was inefficient at passing out the meal trays, leading to cold food. Resident 400, Resident 401, Resident 402, Resident 403, and Resident 404 stated their individual food preferences were not taken into consideration.

2. During a concurrent medication pass observation and interview on 5/12/21, at 1:25 PM, with Registered Nurse (RN) 3, in the medication cart outside Resident 27's room. RN 3 was observed preparing for administration of Gabapentin (used to treat nerve pain and seizures) via G-Tube (a tube inserted surgically through the abdomen into the stomach for nutrition and medications) for Resident 27. RN 3 did not performed hand hygiene before she put on gloves. RN 3 stated she should have performed hand hygiene prior to putting on the gloves. During a review of the facility's policy and procedure (P&P) titled, Administering Medications through an Enteral Tube [through the G-Tube], dated 11/18, the P&P indicated, Steps in the Procedure 1. Wash your hands. Based on observation, interview, and record review, the facility failed to implement infection control practices for four of 59 residents (Resident 16, Resident 27, Resident 28, and Resident 57) when: 1. Restorative Nursing Assistant (RNA) 1 failed to perform hand hygiene while feeding residents. 2. Hand hygiene was not performed prior 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 a self-administration of medication assessment was completed for one of 59 sampled residents (Resident 100). This failure had the potential for unsafe and inappropriate self-administration of medication. Findings: During a concurrent observation and interview on 5/10/21, at 9:50 AM, with Resident 100, in Resident 100's room, one bottle of calcium polycarbophil (used to treat constipation) 625 mg (milligram - a unit of measurement) was found on Resident 100's bedside table inside a basin. Resident 100 stated, I take it [calcium polycarbophil 625 mg] daily. During a concurrent observation, interview, and record review on 5/11/21, at 9:37 AM, with Licensed Vocational Nurse (LVN) 2, in Resident 100's room, Resident 100's physician's orders (PO) were reviewed. LVN 2 was unable to find a PO for the use of calcium polycarbophil 625 mg. LVN 2 stated, Resident 100's medication calcium polycarbophil should not be kept at resident's bedside. LVN 2 was unable to provide a medication self-administration assessment…

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 59 sampled residents (Resident 27) was provided access to call for assistance. This failure had the potential to put Resident 27's health and safety at risk. Findings: During an observation on 5/10/21, at 11:45 AM, in Resident 27's room, Resident 27 was observed in bed. Resident 27's call light was attached to call light wire on the wall. Resident 27 did not have access to a call light. Resident 27 stated she does not know how to call for help. During an observation on 5/12/21, at 12:36 PM, in Resident 27's room, Resident 27 was observed in a wheelchair beside the bed. Resident 27's call light was on the bed and not within reach. During an observation and interview on 5/12/21, at 12:41 PM, in Resident 27's room, Registered Nurse (RN) 3 verified Resident 27's call light was on the bed and not within reach. RN 3 attempted to have Resident 27 push the call light. RN 3 verified Resident 27 was unable to hold the call light securely or activate the call light. Resident 27 stated she did not now how…

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 develop and implement baseline care plans (BCP) for three of 59 Residents (Resident 43, Resident 92, Resident 324) when: 1. Resident 92 had an external urinary catheter (EUC-a tube outside the body that drains the urine). 2. Resident 324 received intravenous hydration (IVF-liquid given into a vein to increase fluids) treatment. 3. Resident 43 had decreased range of motion in the right hand. These failures had the potential to result in staff being unaware of residents' needs. Findings: 1. During a review of Resident 92's admission Record (AR), undated, the AR indicated, Resident 92 was admitted on [DATE], with a diagnosis of neuromuscular dysfunction of bladder (lack of bladder control) and arrived with an EUC. During a concurrent observation and interview on 5/10/21, at 9:08 AM, with Resident 92, in Resident 92's room, Resident 92 was observed in bed with an EUC attached to a drainage bag. During a concurrent interview and record review…

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 Restorative Nursing Program (RNP-nursing interventions provided to ensure residents retain skills learned in therapy) and a splint evaluation were provided for one of 59 residents (Resident 43). This failure had the potential to contribute to Resident 43's, right hand contractures. During a review of Resident 43's Minimum Data Set (MDS-Standardized Assessment Tool), dated 3/9/21, the MDS indicated, Functional Limitations in Range of Motion (flexibility and mobility of joints) O (none) Upper extremity (shoulder, elbow, wrist, and hand). During a concurrent interview and record review on 5/13/21 at 8:38 AM, with Director of Rehabilitation (DOR), the RNP Referral, dated 1/12/21 was reviewed. Resident 43's RNP was referred by Occupational Therapist Registered Licensed (OTRL-focus on maintaining and improving skills for activities of daily living [ADL]), the RNP indicated, Range of Motion (ROM/RNP) Program.Upper Extremity: yes Right Upper Extremity.Type: Active ROM. Reviewed program with RNA (OTRL). Date…

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 label the intravenous (IV) tubing (tube inserted into vein to administer fluids) according to the facility's policy and procedure for one of 59 sampled residents (Resident 52). This failure had the potential for Resident 52 to develop an infection. Findings: During a concurrent medication observation and interview, on 5/12/21, at 8:06 AM, with Registered Nurse (RN) 1, in Resident 52's room, RN 1 connected Vancomycin (used to treat infections caused by bacteria) one gm (gram-a unit of measurement) 250 ml (milliliter) bag to a new set of IV tubing. RN 1 hung the IV Vancomycin bag with tubing connected to Resident 52's right upper arm's PICC Line (peripherally inserted central catheter - a thin, soft, long catheter [tube] that is inserted into a vein). RN 1 did not label the tubing with the start date, time or initials. RN 1 stated the IV tubing should have been labeled with the start date, time and her initials. During a review of the facility's policy and procedure (P&P) titled, Administration Set/Tubing…

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 all medications requiring refrigeration were stored at the proper temperature. This failure had the potential to result in decreased efficacy of medications given to the residents. Findings: During a concurrent observation, interview, and record review, on 5/13/21, at 11:15 AM, with Registered Nurse (RN) 2, in Medication Storage Room Area B, the medication refrigerator was observed to contain eye drops, insulin pens (pre-loaded syringe with medication to lower blood sugar) and suppositories (medication that is administered by inserting into the rectum). RN 2 verified the medications in the refrigerator. The REFRIGERATOR/FREEZER TEMP LOG (TL), (used to document medication refrigerator temperatures), dated 5/2021, was reviewed. The TL was missing temperatures for: 5/10/21 PM, 5/11/21 AM and PM, and 5/12/21 AM. The TL for March 2021, was missing temperatures for: 3/20/21 PM, 3/22/21 AM and PM, 3/23/21 AM and PM, 3/24/21 AM and PM, 3/25/21 PM, 3/26/21 PM, 3/28/21 PM, 3/29/21 AM and PM, 3/30/21 AM and PM,…

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.