San Joaquin Nursing Center And Rehabilitation Cent

Based on observation, interview, and record review, the facility failed to ensure environment was free of accident hazards when the pavement in the facility's designated smoking area had a gap that three of three sampled residents (Resident 1, Resident 2 and Resident 3) reported causing their wheelchairs to get stuck. This failure had the potential to place residents at risk for falls and accidents. Findings:During a concurrent observation of the facility's designated smoking area and interview on 1/15/26 at 9:15 a.m. with Resident 1 and Resident 2, there was a gap in the pavement in the smoking area. Resident 1, who was alert and oriented and was on a wheelchair, stated the gap catches your wheelchair potentially causing residents to fall from their wheelchairs. Resident 1 called the gap a speed bump. Resident 2, also alert and oriented and on a wheelchair, corroborated the statements of Resident 1.During a concurrent observation and interview with the Director of Maintenance (DM) at the smoking area on 1/15/26 at 9:45 a.m., DM measured the gap in the pavement and stated it…

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, Referrals, Social Services, when the facility failed to schedule a follow-up surgeon's (a doctor who removes or repairs a part of the body by operating on the patient) appointment for one of four sampled residents (Resident 1). This failure had the potential for a delay in follow-up care for Resident 1 after surgery (the branch of medical practice that treats injuries, diseases, and deformities by the physical removal, repair, or readjustment of organs and tissues, often involving cutting into the body). Findings:During a review of Resident 1's History and Physical Reports (HPR), dated 7/5/25, the HPR indicated, [Resident 1] who is direct transfer back after suffering a fall resulting in C5-6 fracture [broken neck bone] requiring discectomy [removal] and fusion [joining] as well as R V2 vertebral artery stenosis [artery blockage] at injury site.f/u [follow up] w/ [with] their surgeon in 2 weeks. During a concurrent interview and record review on 8/27/25 at 9:41 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 observation, interview, and record review, the facility failed to ensure fingernails were kept clean and trimmed for one of four sampled residents (Resident 1). This failure had the potential to result in Resident 1 developing infection and skin injury.Findings:During a review of Resident 1's admission Record (AR), dated 8/18/25, the AR indicated, DIAGNOSIS. NEED FOR ASSISTANCE WITH PERSONAL CARE.During a review of Resident 1's SBAR (Situation, Background, Assessment, Recommendations), dated 7/31/25, the SBAR indicated, Change in skin color or condition. Other relevant information: Resident (1) has history of picking at himself and scratching. Nurses noted old scratches over body. Bleeding noted. Resident (1) states he is itching.During a review of Resident 1's Minimum Data Set (MDS - an assessment tool), dated 5/15/25, the MDS indicated on section C (Cognitive Patterns), Resident 1 had a BIMS (Brief Interview for Mental Status) score of 10 (score of 8 - 12 indicates moderately impaired cognition). The MDS indicated on section GG (Functional Abilities), Resident 1 required…

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) on Urinary Catheter (a tube placed in the body to drain and collect urine from the bladder) Care for two of five sampled residents (Resident 1 and Resident 2) when:1. The facility did not monitor placement of urinary catheter for Resident 1.2. The facility did not document urine output according to the plan of care for Resident 2.These failures had the potential for Resident 1 and Resident 2 developing UTI (Urinary Tract Infection - bladder infection).Findings:1. During a review of Resident 1's admission Record (AR), dated 7/10/25, the AR indicated, Resident 1 is a [AGE] year-old male with a diagnosis of OBSTRUCTIVE AND REFLUX UROPATHY (blockage of flow of urine from the kidneys to the bladder and backward flow of urine from the bladder into the ureters and potentially back to the kidneys).During a review of Resident 1's Order Summary Report (OSR), dated 7/10/25, the OSR indicated, Suprapubic…

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 Certified Nursing Assistant (CNA) 2 was wearing proper personal protective equipment (PPE) when entering one of nine sampled residents' (Resident 6) room on contact precautions (to use PPE before entering residents' room with residents known or suspected to be infected with germs that can be spread by direct contact). This failure had the potential to result in spread of infection to other residents, staff, and visitors.2. A Licensed Vocational Nurse (LVN) performed hand hygiene after removing used gloves during a suprapubic catheter (a tube that drains urine from the bladder through a small opening in the lower abdomen) care for one of five sampled residents (Resident 3). This failure had the potential to result in Resident 3 developing urinary tract infection (bladder infection). Findings:1. During a review of Resident 6's admission Record (AR), dated 7/10/25, the AR indicated, Diagnosis. EXTENDED SPECTRUM BETA LACTAMASE (ESBL) RESISTANCE [bacteria that is resistant to common antibiotics…

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, Wound Care, for one of three sampled residents (Resident 1) when wound care orders were not obtained and care plan interventions were not developed and implemented for Resident 1's right and left heel wounds. These failures resulted in Resident 1 not being provided wound care for nine days and had the potential for worsening of Resident 1's right and left heel wounds.Findings:During a review of Resident 1's Admission/readmission Evaluation/Assessment, (AREA) dated 5/7/25, the AREA indicated, Reason for admission: Skilled needs, wound care, the AREA indicated Resident 1 required assistance with activities of daily living: bathing, dressing, toileting, and bed mobility. The AREA indicated, Resident 1 had a wound to the right heel and a closed blister to the left heel (no measurement or description documented of the wound to the right heel or the blister to the left heel).During a review of Resident 1's Baseline Care Plan (BCP - a foundational document in skilled nursing…

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 a safe and sanitary environment for one of three sampled residents (Resident 2 ) when:1. A low air loss mattress (a specialized medical mattress designed to prevent and treat pressure injuries [PI - localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear and/or friction] by providing a combination of air circulation and pressure redistribution) was improperly installed. This failure resulted in Resident 2 hitting his head.2. The wheelchair was not maintained and could not be properly cleaned and sanitized. This failure had the potential for Resident 2 to be exposed the infection and bacteria.Findings:1. During a review of Resident 2's Minimum Data Set, (MDS - a comprehensive assessment tool to evaluate the functional capabilities and health needs of residents) dated 5/18/25, the MDS indicated, Resident 2's BIMS (Brief Interview for Mental Status - standardized assessment tool used to evaluate the 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 interview and record review, the facility failed to ensure: 1. Wound treatments were completed as ordered by the physician for three of three sampled residents (Resident 1, Resident 2, and Resident 3). 2. Weekly wound assessments were completed for two of three sampled residents (Resident 2 and Resident 3). These failures had the potential for delayed wound healing, worsening of wounds, and infection for Resident 1, Resident 2, and Resident 3. Findings: 1. a) During a review of Resident 1's Order Summary Report (OSR), dated 3/17/25, the OSR indicated, Cleanse Wounds to R [right] upper arm, R Forearm [the part of the arm between the elbow and the wrist] and R hand with Dakins [a diluted solution, often used for wound care]. then cut holes for suction and turn wound vac [vacuum] on Q [every] Mon [Monday], Wed [Wednesday], Fri [Friday] & [and] PRN [as needed]. start date 3/17/25. During a concurrent interview and record review on 4/1/25 at 2:39 p.m. with Director of Staff Development (DSD), Resident 1's Treatment Administration Record (TAR), dated 3/2025 was reviewed. The TAR…

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 hospital failed to follow its policy and procedure (P&P) titled, Background Screening Investigations when one of three sampled Licensed Vocational Nurse (LVN) 1's background check was not completed within two days prior to employment. This failure had the potential to expose residents to staff with criminal background. Findings: During a concurrent interview and record review on 4/1/25 at 3:18 p.m. with Director Staff Development (DSD), LVN 1's Employee File (EF) was reviewed. The EF indicated LVN 1's hire date was 2/6/23 and LVN 1's background check was completed on 3/18/23 (one month and six days later). DSD stated the background check was completed after the hire date and background checks should be completed before hire date. During a review of the facility's P&P titled, Background Screening Investigations, dated 3/2019, the P&P indicated, The director of personnel, or designee, conducts background checks, reference checks and criminal conviction checks (including fingerprinting as may be required by state law) on all potential direct…

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 nationally recognized infection prevention and control practices provided by the Centers for Disease Control and Prevention (CDC-agency responsible for preventing infectious diseases) were followed and implemented when: 1. Certified Nursing Assistant (CNA) 1 entered Resident 96's room with Enhanced Barrier Precaution (reduce transmission of multidrug-resistant organisms [MDRO]- bacteria that resist treatment with more than one antibiotic) posted outside the door, without proper Personal Protective Equipment (PPE-refers to gowns, gloves, masks, face shield, or goggles to protect the individual from injury or infection). 2. Hand hygiene was not provided for two of five sampled residents (Resident 38 and Resident 15) before their food trays were delivered. These failures had the potential for infectious diseases to be transmitted to residents. Findings: 1. During a concurrent observation and interview on 2/10/25 at 10 a.m. in Resident 96's room, it was noted Resident 96 was on EBP for a wound on the right…

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 physician orders (PO) for six of twelve sampled residents (Resident 10, Resident 26, Resident 352, Resident 351, Resident 96, and Resident 2) when: 1. Resident 10's blood work (labs) were not drawn monthly as ordered. This failure resulted in the physician to be unaware of the medication levels and the potential for Resident to have seizures. 2. Nursing staff did not put compression stockings on Resident 26. This failure had the potential for Resident 26 to develop a Deep Vein Thrombosis (DVT- blood clot). 3. Nursing staff did not administer intravenous (IV- in the vein) medications at the ordered rate for four out of six residents (Resident 352, Resident 351, Resident 96, and Resident 2) on IV medication Findings: 1. During a review of Resident 10's, admission Record (AR), dated 6/3/19, the AR indicated, Resident 10 has a medical diagnosis of Epilepsy (Seizure Disorder). During a review of Resident 10's, Order Summary Report (OSR), 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 interview and record review, the facility failed to maintain competency (skills and knowledge to perform a job) for one of one Registered Nurse (RN 1) when RN 1 did not have documented competencies to calculate intravenous (IV-within the vein) medication flow rates. This failure had the potential for the residents to receive incorrect doses of medications. Findings: During a concurrent observation and interview on 2/12/25 at 2:30 p.m. with RN 1 in Resident 352's room, Resident 352 had IV Antibiotic Piperacillin-Tazobactam (medication to treat infection) actively infusing through an IV dial-a flow administration set (tubing connection the IV medication to the resident's IV access site) which included a flow rate controller set to open (unmetered flow). Resident 352's IV antibiotic medication label indicated, Piper/Tazo to NACL[sodium chloride] as directed and immediately infuse 100 ML (3.375G) over 1 hour IV via Gravity Flow Every 8 Hours. Flow rate controller was set at 300 ml per hour. RN 1 stated IV medication was flowing at 40 drops per minute. RN 1 stated she checked 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 observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) titled,Discarding and Destroying Medications when: 1. Two of two sampled Licensed Vocational Nurses (LVN 5 and LVN 1) did not discard medication in the pharmacy discard bin. 2. One of two sampled medication carts was left unlocked and unattended. 3. Controlled Drug Records (CDR) were not signed by two nurses. These failures had the potential for medications to go unaccounted for and potentially result in drug diversion. Findings: 1a. During a concurrent observation and interview on 2/10/25 at 9:12 a.m. with Licensed Vocational Nurse (LVN) 5 in Resident 74's room, a white round pill was seen on the floor next to Resident 74's bed. LVN 5 stated it's a pill and she (LVN 5) did not know where the medication came from. LVN 5 stated, It's [unsecure medication] high risk and a resident can pick up the medication and put it in their mouth. LVN 5 put the white pill in the trash can that was in Resident 74's room. LVN 5 stated medication should be destroyed in the blue bin in 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 ensure one of one sampled resident (Resident 96) was determined capable of self-medication administration (the ability of a person to take medication independently) when Resident 96 had eye drops at the bedside to self-administer. This failure had the potential to result in Resident 96 administering medication without the appropriate guidance on how to instill the eye drops in his eyes, possible side-effects, and drug reaction. Findings: During a concurrent observation and interview on 2/10/25 at 10 a.m. with Resident 96 in Resident 96's room, a covered container was on the overbed table and had an ophthalmic solution (artificial tears and lubricant) eye drops at the bedside. Resident 96 stated he had been using and putting eye drops in his eyes, especially after eye surgery. Resident 96 stated the nurses knew I had this eye drops for a long time. Resident 96 stated some nurses had seen him put eye drops in his eyes. During a concurrent observation and interview on 2/11/25 at 8:54 a.m. with Licensed…

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 an advance directive (legal document indicating person's preference for end-of-life treatment decisions) was offered and completed for one of five sampled residents (Resident 16). This failure had the potential for Resident 16's healthcare wishes to not be honored. Findings: During a concurrent interview and record review on 2/11/25 at 2:21 p.m. with Minimum Data Set (MDS, resident assessment tool) Coordinator (MDSC), Resident 16's Medical Record (MR), [undated] was reviewed. MDSC stated she could not find Resident 16's completed AD in the MR. MDSC stated stated Resident 16's AD should be in the MR. During a review of the facility's policy and procedure (P&P) titled, Advance Directives, dated 2013, the P&P indicated, 1. Prior to or upon admission of a resident to our facility, the Social Service Director or designee will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right…

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 their policy and procedure (P&P) titled, Transfer or Discharge, Facility-Initiated, when the facility did not send a notice of transfer to the ombudsman (an advocate for residents of long-term care facilities) for two of two sampled residents (Resident 16 and Resident 38). This failure had the potential to result in Resident 16 and Resident 38 not having an advocate who could inform them of their admission, transfer, and discharge rights and options. Findings: During an interview on 2/11/25 at 9:28 a.m. with Resident 16, Resident 16 stated the facility sent her to the hospital on 1/26/25 and again on 2/9/25. During a concurrent interview and record review on 2/13/25 at 10:49 a.m. with Social Services Director (SSD), Resident 38's Order Summary Report (OSR), dated 11/9/24 was reviewed. SSD stated the OSR indicated Resident 38 was transferred to the hospital on [DATE]. SSD stated she could not find documentation of the Ombudsman notification of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to accurately assess and document urine output for one of one sampled resident (Resident 3) with a urostomy ( opening in the stomach wall to allow urine to pass). This failure resulted in the physician being unaware of accurate measurements of urine output to meet the individualized needs of Resident 3. Findings: During a concurrent observation and interview on [DATE] at 3:21 p.m. with Resident 3 in Resident 3's room, Resident 3 had a urostomy on the left lower section of his abdomen without a bag attached. Resident 3 stated he self catheterizes (inserts a tube into the urostomy to collect urine) himself when needed. During a review of Resident 3's Care Plan Report (CPR), dated [DATE], the CPR indicated, Focus-Bladder: At risk for complications with urinary system . Resident may straight cath [catheter, flexible tube] via Urostomy PRN [as needed]; LN [licensed nurse] to monitor output Q [every] shift. During a review of Resident 3's 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 the discharge summary for two of two sampled residents (Resident 60 and Resident 84) were completed accurately. This failure had the potential for Resident 60 and Resident 84 to miss their follow-up care, not have details of their ongoing care, and could negatively impact Resident 60 and Resident 84's safety. Findings: 1. During a review of Resident 60's admission Record (AR), the AR indicated, Resident 60 was admitted on [DATE] with diagnosis including Parkinsonism (group of symptoms characterized by tremor, slowed movements, rigidity, and postural instability), Muscle Wasting and Atrophy (shrinking and weakening of the muscles), Chronic Obstructive Pulmonary Disease (COPD- lung disease causing restricted airflow and breathing problems), Hepatic Encephalopathy (deterioration of brain function that occurs in people with severe liver disease), and Liver Cirrhosis (severe scarring of the liver). 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.

Based on observation, interview, and record review, the facility failed to ensure foot care was provided for one of one sampled resident (Resident 84). This failure resulted in Resident 84 to not being referred to podiatry (the medical care and treatment for disorders of the feet and toenails). Findings: During a concurrent observation and interview on 2/10/25 at 11:04 a.m. with Resident 84 in Resident 84's room, Resident 84's lower extremities were uncovered. The right great toenail was thick and yellowish in color, and the 2nd, 3rd, 4th, and fifth toenails were also yellowish in color. On the right 2nd, 3rd and 4th toes were small scabs. The 2nd right toe was red. The skin behind the right great toe was thick and dry. The left great toenail was thick, long, and yellowish in color. The left 2nd, 3rd, 4th 5th toenails were also long, and yellowish in color. The skin behind the left great toe was thick and dry. On the left 2nd toe was a scab. Resident 84 stated he had not seen a podiatrist. During a concurrent observation and interview on 2/10/25 at 11:27 a.m. with Registered 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 Performance Evaluations (PE-employee feedback on job performance) for two of eight sampled employees (Certified Nursing Assistant [CNA] 1 and CNA 5) were completed. This failure had the potential for the staff to not be aware of their need for improvement in areas of patient care. Findings: During a concurrent interview and record review on 2/12/25 at 10:10 a.m. with Human Resources Payroll (HR), CNA 1's PE was reviewed. The PE indicated, CNA 1 was hired on 2/6/23. HR stated there was no PE found in CNA 1's employee file. HR stated CNA 1's annual PE had not been completed for the last two years. During a concurrent interview and record review on 2/12/25 at 10:30 a.m. with HR, CNA 5's PE was reviewed. The PE indicated, CNA 5 was hired on 3/15/23. HR stated there was no PE found in CNA 5's employee file. HR stated CNA 5's annual PE had not been completed. During a review of the facility's policy and procedure (P&P) titled, Performance Evaluations, dated February 2023, the P&P indicated, The job performance of each…

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 a medication error rate of less than five percent (5%) during the medication pass observation. The facility has a medication error rate of 9.26 % consisting of five medication errors in a sample size of 54 opportunities for error. Findings: During a concurrent observation and interview on 2/12/25 at 2:30 p.m. with RN 1 in Resident 352's room, Resident 352 had intravenous (IV, in the vein) Antibiotic Piperacillin-Tazobactam (medication to treat infection) actively infusing through an IV dial-a flow administration set (tubing connection the IV medication to the resident's IV access site) which included a flow rate controller set to open (unmetered flow). Resident 352's IV antibiotic medication label indicated, Piper/Tazo to NACL[sodium chloride] as directed and immediately infuse 100 ML (3.375G) over 1 hour IV via Gravity Flow Every 8 Hours. Flow rate controller was set at 300 ml per hour. RN 1 stated the current IV antibiotic flow rate should be at 24 drops per minute. During a concurrent observation…

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 evaluate food preferences for one of one resident (Resident 90). This failure resulted in Resident 90 eating peanut butter and jelly sandwiches every meal, seven days a week, which triggered Resident 90's discontent and anger. Findings: During an interview on 2/10/25 at 10:56 a.m. with Resident 90, Resident 90 stated, Food here is terrible, it is bland. There is no seasoning, and the food is cold (temperature) when I get it. I have always asked for an alternative, but I get peanut butter and jelly sandwich every meal, seven days a week. Resident 90 stated he did not recall speaking to someone from the kitchen. During a concurrent observation and interview on 2/10/25 at 12:16 p.m. with Resident 90, in Resident 90's room, Resident 90 was served his lunch tray with peanut butter and jelly sandwich. Resident 90 refused to eat lunch. Resident 90 stated, Just leave the sandwich, I will eat it later. During a review of Resident 90's Meal Ticket for lunch was reviewed. The meal ticket indicated, Regular, NAS (No added salt), 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.

Based on interview and record review, the facility failed to maintain a complete and accurate medical records for one of two sampled residents (Resident 40). This failure had the potential for Resident 40's physician to be unaware of Resident 40's edema and therefore not ordering appropriate tests or order medication. Findings: During an observation on 2/10/25 at 2:50 p.m. with Resident 40 in Resident 40's room, Resident 40's lower extremities (legs) and both feet were edematous (swollen). During a concurrent observation and interview on 2/12/25 at 2:18 p.m. with Minimum Data Set Coordinator (MDSC), Resident 40's Weekly Nursing Summary (WNS-accurate reflection of the resident's status the previous week), dated 1/18/25, 1/24/25, 1/31/25, and 2/7/25, were reviewed. MDSC was unable to find nursing documentation in the WNS regarding Resident 40's lower extremities edema. MDSC stated there was no mention in the weekly nursing summary of Resident 40's edema. During a concurrent interview and record review on 2/12/25 at 2:32 p.m. with MDSC, MDSC was unable to find an IDT Note addressing…

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 & procedure (P&P) on Binding Arbitration Agreement (BAA - a way to resolve disputes between healthcare providers and residents) for two of two sampled residents (Resident 15 and Resident 33) when admission staff did not document a verbal acknowledgement of the BAA from Resident 15's Family Representative (RP 15) and Resident 33's Family Representative (RP 33). This failure had the potential for facility staff to be unaware if family representatives fully understood the legal document they were signing. Findings: During an interview on 2/12/25 at 10:08 a.m. with RP 15, RP 15 stated she had signed the BAA for Resident 15. RP 15 stated she acknowledged the understanding of the BAA and stated she did not have any questions or concerns. During an interview on 2/12/25 at 10:22 a.m. with RP 33, RP 33 stated she had signed the BAA for Resident 33. RP 33 stated she acknowledged the understanding of the BAA and stated she did not have any issues or concerns. 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.

Based on interview and record review, the facility failed to maintain an effective Quality Assurance Performance Improvement (QAPI-takes a systematic, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes) Program for all 96 residents residing in the facility. This failure had the potential for residents to not receive an acceptable standards of care, and the facility to not be able to identify areas of improvement. Findings: During an interview on 2/13/25 at 9:03 a.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 did not know the QAPI plan. LVN 3 had no knowledge of the facility's process improvement projects. During an interview on 2/13/25 at 9:05 a.m. with LVN 4, LVN 4 did not know what QAPI meant. LVN 4 was not able to articulate the current process improvement projects being worked on in the facility. During a concurrent interview and record review on 2/13/25 at 2:21 p.m. with the Administrator, Administrator stated the facility has a QAPI Committee that meets monthly and/or quarterly and attended by the Medical Director, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a care plan for one of three sampled residents (Resident 1) pressure injury (PI-pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence). This failure had the potential for unmet care needs and Resident 1 ' s wound to worsen. Findings: During a review of Resident 1 ' s Progress Note (PN), dated 7/20/24, the PN indicated Resident was transferred to the acute hospital and was re-admitted back to the facility on 8/2/24. Resident 1 ' s readmission Skin Assessment (RSA), dated 8/2/24, indicated Resident 1 was re-admitted with a PI to right buttock. During a review of Resident 1 ' s Order Summary Report (OSR), dated 8/2/24, the OSR indicated and order for Medihoney (wound gel) to be applied to Resident 1 ' s PI to right buttock every day for 21 days. A review of Resident 1 ' s care plan indicated no documented evidence a care plan was developed for Resident 1 ' s PI to right buttock. During 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) was provided with appropriate pain management. This failure had the potential for Resident 1 ' s pain to not effectively managed. Findings: During a review of Resident 1's admission Record, (AR) the AR indicated, Resident 1 was admitted on [DATE], with diagnoses including pain due to internal orthopedic prosthetic device (a medical implant that replaces or supports a damaged bone or joint) and unilateral osteoarthritis (a degenerative joint condition that primarily affects one side of the body, typically in the knees, hips, or hands). During a review of Resident 1 ' s Admission/readmission Evaluation/Assessment, (AREA) dated 8/23/24, the AREA indicated, Resident 1 Arrived to facility at 2210 (10:10 p.m.) . (Resident 1) has C/O (complaints of) Pain 5/10 on pain scale (numeric pain scale - allow patients to rate their pain. Zero (0) is considered no pain; 1 to 3 is mild pain; 4 to 6 is moderate pain and 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 ensure a baseline care plan was completed within 48 hours of admission for three of three sampled residents (Resident 1, Resident 2, and Resident 3). This failure had the potential for the residents and/or responsible party (RP) to be unaware of the plan of care. Findings: a. During a review of Resident 1 ' s Baseline Care Plan Person-Centered Care Planning (BCPPCCP), dated 8/6/24, the BCPPCCP indicated Resident 1 was admitted on [DATE]. Social Services and Rehabilitative Services sections were completed on 8/12/24 (6 days after admission) and Activities section was completed on 8/27/24 (21 days after admission). b. During a review of Resident 2 ' s BCPPCCP dated 8/19/24, the BCPPCCP indicated, Resident 2 was admitted on [DATE]. Social Services section was completed on 8/22/24 (3 days after admission), Rehabilitative Services section was completed on 8/23/24 (4 days after admission). c. During a review of Resident 3 ' s BCPPCP dated 8/15/24, 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 behavioral health services were provided for one of three sampled residents (Resident 1). This failure had the potential to result in Resident 1 ' s psychosocial needs not being met. Findings: During an interview on 8/27/24 at 1:50 p.m. with Resident 2, Resident 2 stated, (Resident 1) refuses (care) every day, she ' s hardheaded. During an interview on 8/27/24 at 2:30 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated, There are instances when she (Resident 1) refuses (care) and she would put her weight and try to get on the floor. When she starts refusing that ' s when I know she does not want to be touched. She is one that needs to be watched a lot. She does a lot of grabbing of clothing. During a concurrent interview and record review on 8/27/24 at 3:18 p.m. with Director of Nursing (DON), Resident 1 ' s Behavior Symptoms (BS), dated 8/27/24 was reviewed. The BS indicated Resident 1 had episodes of behaviors documented on 8/14/24, 8/15/24, 8/20/24, and 8/21/24. DON stated, There is yelling, pushing,…

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

Based on observation, interview, record review the facility failed to ensure one of the four sampled residents ' (Resident 1) rights to receive a telephone call was honored when the facility did not allow Resident 1 to receive a telephone call. This failure resulted in violating Resident 1 rights to communication. Findings: During an interview on 8/13/24 at 3:45 p.m. with Complainant 1, Complainant 1 stated, Staff did not want to give me her [staff] information because I did not give her my information. I was contacting the resident because I had a confidential call. But the receptionist did not want to hand over the phone to the resident. The receptionist makes it clear that it is impossible to transfer the phones. During an interview on 8/14/24 at 10:55 a.m. with Registered Nurse (RN) 1, RN 1 stated, I tried to ask the lady [Complainant 1], she [Complainant 1] didn ' t want to give us her name and due to HIPPA [Health Insurance Portability and Accountability Act-Federal law to protect sensitive patient health information from being disclosed without consent] I could not give her…

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) received the necessary services for pressure injuries (PI- pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence) to promote healing. This failure had the potential for unmet care needs for Resident 1. Findings: During a review of Resident 1 ' s IDT (interdisciplinary team) - Skin Management Note, (IDTSMN) dated 7/5/24, the IDTSMN indicated, (Resident 1) is non compliant [sic] to turn every 2 hours to offload pressure from Coccyx (tail bone) area and to elevating legs to promote circulation. Risks and benefits explained by the nurse, The (Resident 1) verbalized understanding. During a review of Resident 1 ' s IDTSMN, dated 7/12/24, the IDTSMN indicated, (Resident 1) is non compliant [sic] to turn every 2 hours to offload pressure from Coccyx area and to elevating legs to promote circulation. Risks and benefits explained by the nurse, The (Resident 1) verbalized understanding. During an interview on 8/1/24 at 1:56 p.m.…

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 an individualized care plan for one of four sampled residents (Resident 1) when Resident 1 was frequently pulling out his Gastrostomy Tube (G-Tube-tube inserted through the wall of the abdomen directly into the stomach for nutrition, hydration, and medication). This failure had the potential to result in Resident 1 frequently going to the general acute care hospital for re-insertion of the frequently pulled G-Tube. Findings: During a review of Resident 1's admission Record (AR), dated 4/26/2024, the AR indicated, Resident 1 had a diagnosis Gastrostomy Status. During a review of Resident 1's SBAR (Situation, Background, Assessment, and Recommendation) Communication and Progress Note (SBAR), dated: a) 4/30/2024, the SBAR indicated, Certified Nurse Assistant (CNA) reported to this nurse as she was doing patient care, resident [1] pulled out G-Tube. Resident was sent to emergency room (ER). b) 5/3/2024, the SBAR indicated, Resident [1] pulled G-Tube out. MD [Medical Doctor] notified and ordered this nurse…

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

Based on observation, interview, and record review, the facility failed to follow their policy and procedure titled, Abuse, Neglect, Exploitation, or Misappropriation-Reporting Investigating for one of the three sampled residents (Resident 1), when Resident 1 made an allegation of neglect and facility did not investigate and report to the California Department of Public Health (CDPH). This failure had the potential to result in Resident 1 experiencing continued neglect. Findings: During a concurrent observation and interview on 6/11/24 at 1:35 p.m. with Resident 1, in Resident 1's room, Resident 1 was lying in bed. Resident 1 stated the facility was taking a long time to attend to her needs. Resident 1 stated, I was concerned for my life. I wasn't getting my medication, just let's say this, I asked for help so many times and no one knew where anyone was. I waited for 30 minutes for someone to come and then everyone was mad at me for calling the police. During a review of Residents 1's Minimum Data Set (MDS-Assessment Tool), dated May 9, 2024. The MDS indicated Resident 1 had a Brief…

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 medically related social services for one of three sampled residents (Resident 1), when the Social Services Designee (SSD) did not follow up and provide psychosocial monitoring for Resident 1 after an allegation of neglect. This failure had the potential for Resident 1 experiencing psychosocial distress. Findings: During a review of Residents 1's Progress Notes (PN), dated 5/20/24, the PN indicated, Resident [1] called the police accusing the facility of not taking care of her, when nurse talked to resident [1], she stated nobody has taken care of her or given her medicine since 9 a.m. During a concurrent interview and record review on 6/11/24 at 2:10 p.m. with SSD, SSD stated, I was not aware [of allegation of neglect], I leave at 4:30 p.m. and I wasn't aware she called the cops [police]. SSD stated she did not follow up with Resident 1 after the neglect allegation. SSD was unable to provide documentation of psychosocial assessment. During a review of the facility, Job Description: Social Services Director…

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) was provided advance notice of a room change during a three-day hospital transfer. This failure resulted in Resident 1 being unaware he was returning to a different room. Findings: During a review of Resident1's Bed-Hold and Return Agreement (BHRA) dated 3/24/24, the BHRA indicated, I, [Resident 1], a resident of this facility, hereby request that the facility hold my bed space during my absence during my absence from the facility.[Resident 1's signature]. During a review of Resident 1's Census List (CL) dated 6/27/24, the CL indicated, 4/25/2020.Actual Admission.3/24/2024.Transfer Out to Hospital.3/26/2024 (2 days later) .Room Change.3/27/24.Transfer in from Hospital. During an interview on 5/31/24 at 11:56 a.m. with Director of Nursing (DON), DON stated, Resident 1 went to the hospital on 3/24/24. DON stated, during Resident 1's hospital stay, Resident 1's room was made into a female room for the good of the facility community and Resident 1's belongings were moved to a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to treat one of four sampled resident (Resident 1) with dignity and respect when the facility failed to permit Resident 1 to return to his previous room after three days of being in the hospital. This resulted in Resident 1 moving to a different room without his consent and violation of Resident 1's rights. Findings: During an interview on 4/11/24 at 10:15 a.m. with Director of Nurses (DON), DON stated Resident 1 was transferred to the acute hospital on 3/24/24 and returned to the facility after four days of hospitalization. DON stated Resident 1's previous bed in room [ROOM NUMBER] was no longer available and was moved to room [ROOM NUMBER]. DON stated the facility admitted two female residents in room [ROOM NUMBER] while Resident 1 was out to the acute hospital. During a review of Resident 1's 5-day Minimum Data Set (MDS - a standardized, comprehensive assessment tool) dated 3/28/24 indicated, Resident 1 had a BIMS (Brief Interview 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 interview and record review, the facility failed to ensure physician ordered medications were administered for one of five sampled residents (Resident 1). This failure had the potential for Resident 1 to have adverse outcomes. Findings: During a concurrent interviews and record review on 2/14/24, at 11:24 a.m. with Director of Nursing (DON), DON reviewed Resident 1 ' s Medication Administration Record, dated January 2024. DON confirmed the following: Budesonide [medication used to prevent difficulty breathing, chest tightness, wheezing, and coughing caused by asthma]Inhalation[ breathing in] . 0.5mg [milligrams-unit of measure] inhale orally two times a day for asthma [a chronic lung disease] -Start Date- 01/08/2024 0900 [9 a.m.] -D/C [discontinued] Date- 01/21/2024 2140 [9:40 p.m.] 1/9/24 at 9 a.m. 9 [9=Other/see Nurses Notes] was documented, no documentation Resident 1 was administered Budesonide. 1/12/24 at 9 9.m. 9 [9=Other/see Nurses Notes] was documented, [nurses note indicated Budesonide was not available] no documentation Resident 1 was administered Budesonide.…

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 to: 1. Provide oxygen as ordered by Medical Doctor (MD) for one of three sampled residents (Resident 1). 2. Provide humidified (increase the moisture) oxygen for two of three sampled residents on continuous oxygen (Resident 1, Resident 2). These failures had the potential to negatively impact the residents medical condition. Findings: 1. During a review of Resident 1 admission RECORD (AR), dated 1/9/24, the AR indicated, Resident 1 diagnoses included chronic respiratory failure (inability of the respiratory system to meet the oxygen demands of the body) and Chronic Obstructive Pulmonary Disease (COPD - a condition involving constriction of the airways and difficulty or discomfort in breathing). During a concurrent observation and interview on 1/9/24 at 1:12 p.m. with Licensed Vocational Nurse (LVN) 1, in Resident 1 ' s room, LVN 1 noted the setting for Resident 1 ' s oxygen and stated it was set at 2.5 liters (liter - a unit of measurement). LVN 1 stated Resident 1 ' s oxygen should be set at 3 liters. 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 observation, interview, and record review, the facility failed to ensure professional standards for food service safety and sanitary kitchen conditions. This failure had the potential to cause foodborne illness (illness caused by the ingestion of contaminated food or beverages) for at-risk vulnerable residents when: 1. Cold storage food items were not labeled per facility food service safe storage and guidelines. 2. Dry storage canned products were retained when dented. 3. Persons entering the kitchen and food service area did not adhere to food service safety and sanitary kitchen professional standards. Findings: 1. During a concurrent observation and interview on 1/22/24 at 8:37 a.m. with Dietary Director (DD) in the cold storage room the following was found: A one-gallon (measurement of volume) container of DILL PICKLES SLICES indicated a use by date of 1/15/23. DD stated the item should have been discarded or used by 1/15/23 for the purpose of ensuring the best quality. DD stated the facility process for safe food handling and storage was to label the perishable food…

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) for one of 42 sampled residents (Resident 345) when Resident 345's call light was on the floor. This failure had the potential for Resident 345's needs not being met. Findings: During a concurrent observation and interview on 1/22/24 at 8:38 a.m. with Business Office Manager (BOM) in Resident 345's room, Resident 345 was sitting in a wheelchair, eating her breakfast with her call light on the floor, and not within resident's reach. BOM stated the call light was on the floor and it's not within her (Resident 345) reach. During a review of Resident 345's Nursing Functional Abilities (NFA), dated January 2024, the NFA indicated, Toileting Hygiene is Dependent. During a review of the facility's P&P titled, Answering the Call Light dated 2010, the P&P indicated, The purpose of this procedure is to respond to the resident's requests and needs. 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

Based on interview and record review, the facility failed to ensure an Advance Directive (AD Legal documentation consistent with the known requests or desires of the patient's medical preference) was not in the chart for one of 42 sampled residents (Resident 50). This failure had the potential for Resident 50 to not receive the necessary treatment when needed. Findings: During a concurrent interview and record review on 1/25/24 at 2:31 p.m. with Regional Nurse Consultant (RNC) 1, Resident 50's admission Record (AR), undated was reviewed. The AR indicated, Resident 50 had executed an AD before 1/03/20. Upon reviewing record no AD was found in Resident 50's chart. RNC 1 stated, We don't have a copy on file of advance directive. During a review of facility's policy and procedure (P&P) titled, Advance Directives, dated 2022, the P&P indicated, The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy. 1. If the resident or the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one of 42 sampled residents (Resident 24), had a notification sent to the long-term care ombudsman (Ombudsman are representatives that assist residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences) when Resident 24 was transferred to the hospital. This failure had the potential to result in Resident 24 not being protected from an inappropriate discharge and not having access to an advocate who can inform them of their options and rights. Findings: During a concurrent interview and record review on 1/25/24 at 2:31 p.m. with Social Services Director (SSD), the facility's Admission/Discharge To/From Report (AD), dated 11/1/23-11/30/23 and 12/1/23-12/31/23 was reviewed. The AD indicated Resident 24 was transferred to the hospital on [DATE] and 12/12/23, and the ombudsman office was sent the AD on 1/3/24. SSD stated the November and December AD was sent in January. SSD confirmed the AD…

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) when: 1. Resident 5 did not have a smoking assessment completed. This failure had the potential to result in Resident 5 not being assessed and jeopardize his safety. 2. Resident 7 did not have a weekly skin assessment of a pressure ulcer (Injury to skin and underlying tissue resulting from prolonged pressure on the skin). This failure had the potential for Resident 7 to not receive needed care and treatments. Findings: 1. During a concurrent interview and record review on 1/23/24 at 10:56 a.m. with Regional Nurse Consultant (RNC) 1, Resident 5's NURSING-RNA WEEKLY (LICENSED STAFF ATTESTATION OF SIGNATURE) Type: Nursing -Smoking Obs, undated was reviewed. RNC 1 stated the assessment for 4/20/23 was not completed and it should have been done quarterly. During a review of the facility's P&P titled, Smoking Policy-Residents, dated 2022, the P&P indicated, This facility has established and maintains safe resident smoking practices.8. A resident's ability to smoke safely is re-evaluated…

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 42 sampled residents (Resident 3) had a comprehensive care plan (includes measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs) developed and implemented for his dental concerns. This failure had the potential to negatively impact Patient 3's safety, psychosocial, and care needs. Findings: During a concurrent observation and interview on 1/22/24 at 9:38 a.m. with Resident 3 in the resident's room, Resident 3 was seen lying on his bed watching TV. Resident 3 stated he had a loose tooth and stated he had seen the Dentist but did not know when the Dentist was going to come back to the facility to remove the loose tooth. During a concurrent interview and record review on 1/14/24 at 12:10 p.m. with Regional Nurse Consultant (RNC) 1, Resident 3's Electronic Health Record (EHR) was reviewed. The EHR indicated, no care plan was developed for Resident 3's dental concerns. RNC 1 stated there was no dental care plan for Resident 3 and it should have…

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

Based on observation, interview, and record review, the facility failed to ensure physician ordered anticoagulant (blood thinner medication) was available for administration for one of 42 sampled residents (Resident 65). This failure had the potential for adverse health outcomes. Findings: During a review of Resident 65's Order Entry (OE), dated 8/16/23, the OE indicated, Clopidogrel Bisulfate [generic name for Plavix - blood thinner medication to prevent blood clots] Tablet 75 MG [milligram unit of measure] Give 1 tablet by mouth one time a day for HX [history] of PVD [peripheral vascular disease - narrowing of blood vessels in arms and legs]. During a concurrent observation and interview on 1/24/24 at 8:51 a.m. with Licensed Vocational Nurse (LVN) 1 outside of Resident 65's room, LVN 1 was preparing medications to be administered. LVN 1 stated the cart did not have Resident 65's dose of Plavix, and she would need to check the automated drug dispenser (ADD machine that automatically dispenses drugs/medications) in the medication room. LVN 1 stated she checked the ADD and there 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 ensure its medication error rate was less than 5% for two of eight sampled residents (Resident 65 and Resident 39). This failure had the potential for adverse health outcomes related to incorrect medication administration. Findings: 1. During an observation on 1/24/24 at 8:51 a.m. outside of Resident 65's room, Licensed Vocational Nurse (LVN) 1 prepared Resident 65's medications for administration. LVN 1 administered Losartan (medication to lower blood pressure) and Sucralfate (antacid to treat or prevent stomach ulcers) to Resident 65. During a review of Resident 65's Medication Admin Audit Report (MAAR), dated 1/24/24, the MAAR indicated Resident 65 was scheduled to receive Losartan 25 mg (milligram - unit of measure) Give 1 tablet by mouth one time a day for hypertension at 1:00 p.m. [Losartan was given during observation at 8:51 a.m.]. The MAAR indicated Resident 65 was to receive Sucralfate 1 gm (gram - unit of measure) Give 1 tablet by mouth three times a day for a history of GI Bleed scheduled at 7:00…

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 interview and record review, the facility failed to ensure one of 42 sampled residents (Resident 2) had a TSH (thyroid stimulating hormone; primary stimulus for thyroid hormone production by the thyroid gland) level ordered. This failure had the potential to result in Resident 2 having a continued, unplanned weight gain. Findings: During a concurrent interview and record review on 1/25/24 at 9:37 a.m. with the Minimum Data Set nurse (MDSN), Resident 2's SBAR (Situation, Background, Assessment, Recommendation) Communication Form and Progress Note (PN) for RNs [Registered Nurses]/LPN [Licensed Practical Nurse]/LVNs [Licensed Vocational Nurses], dated January 2024, was reviewed. The PN indicated, Weight gain of 18 lbs [pounds] (8.4%) in 90 days . Recommendations from IDT [Interdisciplinary Team] meeting, Check TSH levels . Recommendations of Primary Clinicians (if any): MD [medical doctor] notified and in agreement with IDT recommendations. MDSN stated there is no MD order for a TSH level, and there are no TSH level results in Resident 2's medical record (MR). 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 observation and interview the facility failed to provide a safe and sanitary environment for two of 42 sampled residents (Resident 39 and Resident 2) when hand hygiene was not provided before the food tray was delivered. This failure had the potential to adversely affect Resident 39 and Resident 2's health. Findings: During a concurrent observation and interview on 1/22/24 at 1:42 p.m. with Resident 39 in resident's room, Resident 39 was given his food tray by admission Coordinator (AC). Resident 39 was asked if he had been offered or provided with hand sanitizing prior to him receiving his food tray. Resident 39 stated he had not sanitized his hands before his tray was delivered. During a concurrent observation and interview on 1/22/24 at 1:44 p.m. with AC in Resident 39's room. AC delivered Resident 39's food tray without providing Resident 39 with hand hygiene. AC stated the residents usually get their hands sanitized before meals, but Resident 39 did not receive hand hygiene and he should have. During a concurrent observation and interview on 1/22/24 at 1:49 p.m. with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was assessed (evaluated) after an unwitnessed fall. This failure had the potential for injuries due to unsafe movement of Resident 1 by the Certified Nursing Assistant (CNA) from the floor to the wheelchair. Findings: During a review of the Facility's Reported Incident (FRI), dated 8/14/23, the FRI indicated, Resident 1 was found on the floor and her hip did not look right, Resident 1 was sent to emergency room (ER) and had a dislocated right hip (an injury in which the hipbone is displaced from its normal position). During a review of Resident 1's admission Record (AR), dated 8/22/23, the AR indicated, Resident 1 was initially admitted to the facility on [DATE] for difficulty in walking and readmitted to the facility on [DATE] for fracture (broken bone) of the right hip. During a review of Resident 1's Minimum Data Set (MDS – standardized resident screening tool), dated 7/15/23, the MDS…

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

Based on interview and record review, the facility failed to notify the Ombudsman (provides resolutions to issues, complaints, and concerns made by residents in licensed facilities. Also protects the rights of residents and responds to allegations, abuse, and neglect. Provides consumer information on literature and prevents inappropriate transfers and evictions) of discharge for one of four sampled residents (Resident 1) when Resident 1 was inappropriately discharged home. This failure resulted in Resident 1 being discharged inappropriately and was sent to the hospital after only six hours of discharge. Findings: During an interview on 8/4/23 at 12:09 p.m. with Ombudsman, Ombudsman stated, After reviewing all the notices from [facility] for the month of July, including the date you provided, it [discharge notice] appears that we have not received a discharge notice for resident [1]. During a concurrent interview and record review on 8/9/23 at 3:43 p.m. with Director of Social Services (DSS), Resident 1's Medical Records was reviewed, DSS stated, she did not send a discharge…

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.