The Rehabilitation Center Of Bakersfield

Based on observation, interview, and record review, the facility failed to provide food at a palatable and safe temperature to one of 29 sampled residents (Resident 102), when Resident 102 was served cold soup during the meal. This failure had the potential to result in decreased meal satisfaction, inadequate nutritional intake, and increased risk of health complications such as unintended weight loss or dehydration. Findings:During an observation on 1/12/2026 at 5:02 p.m. in the dining hall, Certified Nursing Assistant (CNA) 5 served Resident 102 a cup of French onion soup. Resident 102 took a sip of the soup and shouted the soup was cold and she did not want the soup anymore.During an observation on 1/12/2026 at 5:05 p.m. in the dining hall, CNA 5 got a replacement cup of French onion soup and served again to Resident 102. Resident 102 took a sip of the soup and shouted, that is cold, I don't want it. Resident 102 pushed the cup of soup towards the other end of the dining table.During a concurrent observation and interview on 1/12/2026 at 5:07 p.m. with the Dietary Manager (DM) in…

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 four of four outside dumpsters' lids were closed. This failure had the potential to attract pests and/or rodents that carried diseases and could result in food borne illness (a sickness caused by consuming food, or drinks contaminated with harmful substances) in a medically fragile population of 146 residents.Findings:During a concurrent observation and interview on 1/12/2026 at 1:57 p.m. with the Dietary Manager (DM) outside in the trash area, four of four dumpsters had overflowing trash with lids being unable to close, and multiple items of trash scattered around the dumpsters on the ground that contained food items. The DM confirmed that trash should not be laying on the ground and the lids should be covering all trash in the dumpsters.During an interview on 1/14/2026 at 2:03 p.m. with the Registered Dietician (RD), the RD stated she oversees the kitchen and lids to the dumpsters should be fully closed, to keep rodents out.During a review of the U.S [United States] Food and Drug Administration'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure oversight and monitoring of antibiotic use for one of 29 sampled residents (Resident 44) when Resident 44 was administered two separate antibiotics without documented indication and appropriate physician review. This failure resulted in Resident 44 receiving two unnecessary medications with the possibility of adverse drug reactions and antibiotic resistance.Cross reference to F757Findings:During a review of Resident 44's Face Sheet, Resident 44 was admitted to the facility on [DATE] with diagnoses to include chronic kidney disease stage 3, and type 2 diabetes mellitus (chronic condition when the body doesn't produce or use sugar effectively).During a concurrent interview and record review on 1/16/2026 at 9:18 a.m. with Infection Preventionist (IP) 2, the following documents were reviewed:-Resident 44's Physician Orders (PO), dated 12/16/2025, the PO indicated to administer azithromycin 500 mg (milligram-unit of measurement) for three days for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure documentation was maintained to verify that influenza (a highly contagious viral infection of the respiratory tract) and pneumococcal (a bacterial infection that may cause pneumonia and other serious illnesses) immunizations were offered in accordance with facility policy to one of five residents (Resident 2) reviewed for immunizations. This failure placed Resident 2 at risk for acquiring influenza and/or pneumococcal disease.During a review of Resident 2's face sheet (a document containing demographic information), it was noted that the resident was admitted to the facility on [DATE] with diagnoses that included Metabolic Encephalopathy (brain dysfunction caused by a chemical imbalance related to an underlying illness) and Pneumonitis (inflammation of lung tissue) due to aspiration of food and vomit.During a concurrent interview and record review on 1/15/2026 at 9:24 a.m. with the Infection Preventionist (IP) 2, IP 2 stated she was unable 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow infection prevention and control procedures for COVID-19 (a highly contagious respiratory infection) in accordance with the facility's vaccination policy, when:1. Resident 124 declined the COVID-19 vaccination; however, there was no documentation that the facility provided education regarding the risks and benefits of the vaccine. This failure posed the potential risk of COVID-19 transmission and compromised Resident 124's ability to make an informed decision regarding vaccination. 2. There was no documentation verifying Certified Nursing Assistant (CNA 1) was vaccinated for influenza and COVID-19. This failure risked 146 residents at risk of exposure of influenza and COVID-19.1. During a review of Resident 124's face sheet (a document containing demographic information), it was noted that the resident was admitted to the facility on [DATE] with a diagnosis that included Diabetes Mellitus (a chronic disease associated with abnormally high levels…

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) was served food at a palatable temperature. This failure had the potential for Resident 1 to not eat, lose weight, and not meet his nutritional needs.Findings:During a concurrent observation and interview on 8/1/25 at 1:24 p.m. with the Dietary Supervisor (DS), in Resident 1's room, Resident 1 was about to eat his lunch. DS checked the meat's temperature in Resident 1's the meal tray. DS stated the temperature was 100 (Fahrenheit-temperature measurement). During a concurrent observation and interview on 8/1/25 at 1:30 p.m. with DS, at the nurses' station, DS checked the temperature of the green beans and the salad in the test tray (a sample meal tray used to assess the quality and accuracy of food service, ensuring it aligns with dietary requirements and standards). DT stated the green beans were at 100 and the salad was at 50 .During a concurrent observation and interview on 8/1/25 at 1:38 p.m. with Resident 1 in his room, Resident 1 had his meal tray on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Serve residents food timely and at a palatable (pleasant to taste) temperature for two of three sampled residents (Resident 1, Resident 2). 2. Document food temperatures prior to distributing the residents meals for two of three sampled residents (Resident 1, Resident 2). These failures had the potential for reduced resident meal intake and the potential for the residents to contract food borne illness. Findings: 1. During a review of Resident 1's Minimum Data Set (MDS -a standardized assessment to evaluate a resident ' s functional abilities and healthcare needs), dated 1/30/25, under the section Brief Interview for Mental Status (BIMS - an assessment of cognition [how well a person thinks, remembers, and learns], the BIMS score was 15 (cognition intact). During an interview on 6/16/25 at 12:30 p.m. with Resident 1, Resident 1 stated at times (not specific) his meals come in very late, and the food can be cold when it is delivered.…

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 six sampled residents (Resident 1) was provided a meal tray for lunch. This failure had the potential for Resident 1 to experience unmet nutritional needs. Findings: During an observation on 1/30/25 at 1 p.m., with Resident 1, in Resident 1's room, Resident 1's roommate (Resident 3) was provided his meal tray by Certified Nursing Assistant (CNA) 1. When this surveyor exited Resident 1's room approximately 34 minutes later, Resident 1 had not received a meal tray. During a concurrent observation and interview on 1/30/25 at 1:34 p.m., with Licensed Vocational Nurse (LVN) 1, in the hallway, there were no meal carts left in the hallway. LVN 1 stated all lunch trays were passed to the residents and then picked up and returned to the kitchen. LVN 1 stated after speaking with several staff, none of the CNAs had passed Resident 1 a meal tray. During an interview on 1/30/25 at 1:36 p.m., with CNA 2, CNA 2 stated she was assigned to Resident 1. CNA 2 stated she did not provide Resident 1 a meal tray.…

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 the medication error rate was not greater than five percent (%) when five medication errors occurred within 39 opportunities resulting in a 12.82% error rate for three of six sampled residents (Resident 45, Resident 74, and Resident 107). This failure had the potential for Resident 45, Resident 74, and Resident 107 not receiving the full therapeutic effects of the medications and potential for adverse health outcomes. Findings: During an observation on 1/7/25 at 8:59 a.m. with Licensed Vocation Nurse (LVN) 2 in Resident 45's room, LVN 2 administered Mucus Relief (medication to help relieve congestion) 400 mg (milligrams) to Resident 45. During a concurrent interview and record review on 1/7/25 at 2:22 p.m. with LVN 2, Resident 45's Medication Administration Record (MAR), dated January 2025 was reviewed. The MAR indicated the following medications: Mucinex Allergy Tablet (Fexofenadine HCl - medication to treat allergies) Give 1 tablet by mouth two times a day for coughing/allergies and Fluticasone…

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. No Enhanced Barrier Precaution (EBP-infection control strategy that uses Personal Protective Equipment [PPE-equipment worn to minimize exposure to a variety of hazards to reduce the spread of infections]) signage and no PPE supplies outside an EBP room for one of four sampled residents (Resident 18). 2. An opening in the wall between one of three clean and dirty utility rooms present. 3. One of one janitorial cart's trash bin did not have a lid. These failures had the potential to result in the spread of infection to Residents, staff, and visitors. Findings: 1. During a review of Resident 18's admission Record, (AR) dated 1/8/25, the AR indicated Resident 18 had a gastrostomy (GT-tube inserted into an opening in the stomach for food). During a review of Resident 18's Physician Order, (PO) dated 1/4/25, the PO indicated, RESIDENT ON ENHANCED BARRIER PRECAUTION (EBP) TO REDUCE THE SPREAD OF MDRO [Multidrug-Resistant Organism that have become resistant to multiple…

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 an adaptive call light (specially designed call button for individuals with physical disabilities or limited mobility to easily signal for assistance) was provided for one of one sampled dependent resident (Resident 80). This failure resulted in unmet needs due to being unable to call staff. Findings: During a concurrent observation and interview on 1/6/25 at 9:30 a.m. with Resident 80 in Resident 80's room, the call light was wrapped around the right upper side rail. Resident 80 had contractures in his right hand and his left arm was limp. Resident 80 stated he did not have the coordination to use the call light and he whistled to call staff for assistance. During a concurrent observation and interview on 1/7/25 at 1:56 p.m. with Certified Nursing Assistant (CNA) 2 in Resident 80's room, Resident 80's call light was observed tied to the right upper side rail. CNA 2 stated Resident 80 would not be able to use this call light. During an interview on 1/9/25 at 9:35 a.m. 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 Based on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Personal Property for one of one sampled resident (Resident 13) when Inventory of Personal Effects (IPE) form was not reviewed for accuracy during Resident 13's quarterly care plan conference. This failure resulted in incorrectness of Resident 13's IPE based on her current personal belongings, the inability to verify missing items, and the potential of those missing items not being replaced because they are not on the IPE. Findings: During an interview on 01/07/25 at 01:21 p.m. with Resident 13, Resident 13 stated she had personal belongings missing, including a gold box shaped like an egg that she had received at Christmas. Resident 13 stated she had reported the missing items and she did not see facility staff making an effort to find them. During a review of Resident 13's IPE, dated 7/30/23, the IPE indicated the last review and update of Resident 13's personal effects was on 7/23/23. The IPE indicated…

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

Based on interview and record review, the facility failed to ensure the facilities grievance process was followed for one of three sampled residents (Resident 16). This failure had the potential for Resident 16 to be subject to continued abuse and resulted in Resident 16 being unaware of the plan of correction or outcome of the grievance investigation. Findings: During an interview on 12/30/24 at 2:39 p.m. with Resident 16, Resident 16 stated he filed a grievance with Social Service Assistant (SSA) regarding abuse allegations (12/23/24). Resident 16 stated the facility had not followed up with him regarding the grievance. During a review of Resident 16's Resident Grievance/Complaint Investigation Report,(RGCIR) dated 12/23/24, the RGCIR indicated the Resident 16's grievance report was assigned to the Administrator. The RGCIR indicated, Assigned Department's response to Grievance (includes any actions taken, investigations plan to correct: [space to indicate if completed was blank] Was the grievance confirmed (space to indicate if completed was blank) Department Head Signature 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 follow their policy and procedure (P&P) titled, Abuse Investigation and Reporting, for one of three sampled residents (Resident 115). This failure had the potential for Resident 115 and the facility's residents to be at risk for abuse. Findings: During an interview on 12/30/24 at 12:41 p.m. with Director of Nursing (DON) 2, DON 2 stated Social Services Assistant (SSA), Case Manager (CM), and herself were responsible for the investigation of the allegations of physical abuse for Resident 115 by Certified Nursing Assistant (CNA) 1. DON 2 stated she interviewed Resident 115, Resident 115's family, Resident 115's roommate and staff as part of the alleged abuse investigation. DON 2 stated she did not interview any other residents regarding the care provide by CNA 1. During an interview on 12/30/24 at 3:23 p.m. with SSA, SSA stated she was not involved in the investigation of Resident 115's allegations of physical abuse. During an interview on 12/30/24 at 3:54 p.m. with CM, CM stated she was not involved in the investigation of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Notice of Transfer/Discharge, when the facility did not send a notice of transfer to the ombudsman (advocate for residents in a long-term care facilities) for two of two sampled residents (Resident 24 and Resident 69). This failure had the potential for Resident 24 and Resident 69 to not have an advocate to review their admission, transfer, and discharge rights and options. Findings: During a concurrent interview and record review on 1/9/25 at 9:10 a.m. with Minimum Data Set Coordinator (MDSC), Resident 24's Medical Record (MR) was reviewed. MDSC stated Resident 24 was transferred to the hospital on [DATE]. MDSC stated he was unable to provide a transfer and discharge form for Resident 25 which indicated the Ombudsman was notified. During a concurrent interview and record review on 1/9/25 at 11 a.m. with Social Services Assistant (SSA), Resident 24's MR was reviewed. SSA stated she could not find…

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, Comprehensive Person-Centered Care Planning for two of three sampled residents (Resident 1 and Resident 64) when 1. When a conservator (resident's legal representative) did not participate in Patient 1's care conference. This failure resulted in Resident 1's conservator to not participate in Patient 1's plan of care or be aware of changes in plan of care. 2. When a comprehensive care plan did not include individualized goals and interventions for restorative mobility for Patient 64. This failure had the potential for Patient 64 to not reach full mobility and function potential. Findings: 1. During a review of Resident 1's admission Record (AR), dated 1/7/25, the AR indicated, Diagnosis. Dementia [a decline in mental abilities that affects thinking, memory, and reasoning]. Altered Mental Status. Cognitive Communication Deficit [unable to communicate effectively due to problems with how their brain processes information]. During a review of Resident 1's Notice to Conservatee 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: 1. Ensure a verbal order (VO) for one of six sampled residents (Resident 116) was entered into the medical record (MR). This failure had the potential for increased risk of medication errors, potential patient harm due to incorrect treatment, and resulted in an incomplete medical record. 2. Follow their policy and procedure (P&P) titled, Medication - Administration for one of six sampled resident (Resident 45) when incorrect dose of medication was given. This failure had the potential for Resident 45 to have adverse health outcomes. Findings: 1. During a concurrent interview and record review on 1/9/25 at 2 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 116's Progress Notes, (PN) dated 10/21/24 and the Orders, dated October 2024 were reviewed. The PN indicated, Resident [116] noted with limit [sic] response, pale in color and diaphoretic [sweating]. BS [blood sugar] 38, BP [blood pressure]147/67, O2 [oxygen] 90%. Glucose Gel [medication to increase the blood sugar] administered at 1715 [5:15 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 interview and record review, the facility failed to ensure for one of one sampled resident (Resident 64): 1. Physician's orders were followed for the Restorative Nursing Assistant (RNA) therapeutic program (program designed to help residents maintain or improve their functional abilities). This failure had the potential to result in decline of Resident 64's strength and mobility. 2. The RNA completed RNA program written weekly summaries. This failure resulted Resident 64's progress towards regaining independence in daily activities was not monitored which had the potential for a decline in function and mobility. Findings: 1. During a review of Resident 64's physician orders (PO), dated 10/22/24, the POs indicated Resident 64 was to have RNA therapy five times a week as part of the RNA program. Resident 64's RNA therapy program was to include: a. Therapy exercises using rickshaw (exerciser for wheelchair dependent people to strengthen their arms and shoulder muscles) with 20 lbs (pounds) and or alternate of pulley 4 for 2.5 plates for 15 minutes or as tolerated b. AROM…

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 eight sampled employees (Supervisor Licensed [SL] 3) had an annual performance evaluation completed. This failure had the potential to result in compromise to the health, safety, and well-being of residents. Findings: During an interview on 1/8/25 at 11:07 a.m. with Director of Nursing (DON), DON stated employees must have performance evaluations completed annually. During a concurrent interview and record review on 1/8/25 at 3:01 p.m. with Director of Staff Development (DSD), SL 3's personnel file (PF) was reviewed. SL 3's PF indicated SL 3's date of hire was 12/24/23 and there were no performance evaluations in the file. DSD stated SL 3 should have had a performance evaluation annually. During a review of the facility's Policy and Procedure (P&P) titled, Compliance as a Component of Employee Performance, dated 9/17/21, the P&P indicated, PURPOSE: Effective compliance programs required adherence to compliance as well as assurances that an employee's performance is evaluated and measured against 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 menus were followed for two of four sampled residents (Resident 1 and Resident 2) when Resident 1 and Resident 2 received smaller portion sizes. This failure had the potential to result in Resident 1 and Resident 2 experiencing weight loss due to receiving smaller portion sizes. Findings: During a review of Resident 1's Order Summary Report (OSR), dated 12/23/24, the OSR indicated, Regular-large portion diet. requesting to have large portion of all meals. During a review of the facility's Winter Menus (WM), dated 12/23/24, the WM indicated residents on large portions diet receive four ounces of blended juice, one cup of grits hot cereal, two fried eggs, two slices of wheat toast, two teaspoons of margarine, a parsley sprig, and eight ounces of milk for breakfast. During an interview on 12/23/24 at 11:16 a.m. with Resident 1, Resident 1 stated, I only got one egg and one piece of bread for breakfast this morning. That's very limited. It's not enough. I used to get three eggs scrambled, 1 hashbrown, 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 observation, interview, and record review, the facility failed to ensure food prepared by the facility were prepared in accordance with professional standards for food service safety. This failure had the potential for the facility ' s resident to suffer from food born illnesses. Findings: During a review of facility Menu for 11/6/24 (breakfast) the menu indicated, French Toast with warm syrup breakfast Meat (sausage and bacon) Corn Flakes Grape Juice. During a review of facility Menu for 11/5/24 (dinner) the menu indicated, Crispy Fish Fillet Seasoned Fries Fresh Vegetable Blend Baked Apricot Crunch. During an observation on 11/6/24 at 6:46 a.m. in the facility ' s kitchen, tray line was observed. The following foods were noted: eggs, French toast, sausage, beacon, hashbrowns, hot cereal, cold cereal, milk, and juice were served. During concurrent observation, interview, and record review, on 11/6/24 at 8 a.m. with Dietary Supervisor (DS), confirmed sausage, bacon, and hashbrowns were served for the breakfast meal service. DS confirmed dinner was prepared and served 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) were treated with respect and dignity. This failure had the potential for Resident 2 to suffer emotional distress. Findings: During a review of Resident 2's admission Record, (AR) the AR indicated, Resident 2 was admitted on [DATE], with diagnoses including hemiplegia (condition that causes paralysis or weakness on one side of the body) and hemiparesis (a condition that causes weakness or an inability to move on one side of the body) following cerebral (occurs as a result of disrupted blood flow to the brain and you may become paralyzed on one side of the body, or lose control of certain muscles), aphasia (a language disorder that makes it difficult to understand, speak, read, and write) following cerebral infraction (a serious condition that occurs when blood flow to the brain is blocked, resulting in brain tissue death), and anxiety disorder (mental health conditions that cause uncontrollable 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 investigate timely and protect one of three sampled residents (Resident 1) when Resident 1 reported missing money and reports of Resident 1 giving money to a staff member (Activity Director). This failure had the potential for Resident 1 to have funds misappropriated. Findings: During a review of Resident 1's AR, the AR indicated, Resident 1 was admitted on [DATE], with diagnoses including unspecified dementia (a decline in mental ability that affects a person's daily life; characterized by a loss of cognitive functioning, such as thinking, remembering, and reasoning, that worsens over time), Bipolar disorder (a serious mental illness that causes extreme shifts in mood, energy, thinking, behavior, and sleep), and schizophrenia (a serious mental disorder in which people interpret reality abnormally). During a review of Resident 1's MDS, dated 9/22/24, the MDS indicated, Resident 1's BIMS score was 11 (a score of 8 to 12 indicates moderately impaired…

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 injury of unknown origin was reported and investigated for one of three sampled residents (Resident 1). This failure had the potential to negatively affect Resident 1's health and safety. Findings: During a review of Resident 1 ' s SBAR (Situation, Background, Appearance, Review and Notify- communication tool), dated 10/9/24, the SBAR indicated, discoloration/swelling to right eye. During an interview on 10/22/24 at 1:30 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 1 was noted with a discoloration on his right eye a few weeks ago (10/9/24). During an interview on 10/22/24 at 1:44 p.m. with Licensed Vocational Nurse (LVN), LVN 1 stated she was reporting the injury of unknown origin to the Director of Nursing (DON) and Administrator. During an interview on 10/22/24 at 2:02 p.m. with LVN 2, LVN 2 stated Bruising or redness cannot be explained must be investigated. LVN 2 stated, We don ' t know if it is abuse. During a concurrent interview and record review on 10/22/24 at 2:16 p.m. with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Fall Management Program, for one of three sampled residents (Resident 1). This failure had the potential for accidents and injury. Findings: During a review of Resident 1's Minimum Data Set, (MDS - an assessment tool) dated 7/13/23, the MDS indicated, Resident 1's BIMS (Brief Interview for Mental Status) score was 99 (a score of 99 indicates the resident was unable to complete the interview). The MDS indicated Resident 1 had short-term and long-term memory problems. The MDS indicated Resident 1 ' s cognitive skills for daily decision making were severely impaired (never/rarely made decisions). Resident 1 needed substantial /maximal assistance (helper does more than half the effort) with roll left and right (the ability to roll from lying on back to left and right side, and return to lying on back on the bed), Resident 1 was dependent (helper does all the effort) for sit to lying (the ability to move from…

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 Medical Doctor (MD) orders for incentive spirometry (ISP - a breathing exercise that uses a device to help people inhale slowly and deeply to improve lung function) for three of four sampled residents (Resident 1, Resident 2, Resident 3). This failure resulted in MD orders not being followed and had the potential for negative health consequences. Findings: During a review of Resident 1's Order Summary (OS), dated 11/4/24, the OS indicated, Resident 1 had an MD order for ISP to be given every shift (morning, afternoon, night) until 11/19/24. During a review of Resident 1's Minimum Data Set (MDS- an assessment tool) under the section BIMS (Brief Interview for Mental Status – an assessment of cognition [mental processes including perception, memory, and thought]), dated 11/11/24, the BIMS indicated, Resident 1 had a score of 15 (cognition intact). During a concurrent observation and interview on 11/12/24 at 11:17 a.m. with Resident 1,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to accurately document services given for incentive spirometry (ISP - a breathing exercise that uses a device to help people inhale slowly and deeply to improve lung function) for three of four sampled residents (Resident 1, Resident 2, Resident 3). This failure resulted in falsification of documentation and had the potential for adverse health outcomes for Resident 1, Resident 2, and Resident 3. Findings: During a review of Resident 1's Order Summary (OS), dated 11/4/24, the OS indicated, Resident 1 had an MD (Medical Doctor) order for ISP to be given every shift (morning, afternoon, night) until 11/19/24. During a review of Resident 1's Minimum Data Set (MDS- an assessment tool) under the section BIMS (Brief Interview for Mental Status – an assessment of cognition [mental processes including perception, memory, and thought]), dated 11/11/24, the BIMS indicated, Resident 1 had a score of 15 (cognition intact). 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 interview and record review, the facility failed to follow its policy and procedure (P&P) on abuse prevention and management when one of five sampled residents (Resident 1) was not assessed for signs of emotional distress after a reported abuse incident. This failure had the potential to result in Resident 1 suffering from psychosocial harm due to lack of assessment for emotional distress. Findings: During a review of SOC 341 (Report of Suspected Dependent Adult/Elder Abuse), dated 10/8/24, the SOC 341 indicated, (Resident 1) sent her daughter to pull some money out and her balance was zero. Per resident, the daughter had the bank pull up a camera to see who had used her mothers account and it was (Family Member [FM] 1). She stated (FM 1) was not accepting her phone calls but he finally answered and he confessed to taking her money and apologized. During an interview on 10/21/24 at 2:55 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she was not aware of any monitoring for emotional distress done for Resident 1. During an interview on 10/21/24 at 3:36 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.

Based on interview and record review, the facility failed to complete an investigation of an abuse incident within five working days for one of five sampled residents (Resident 1). This failure had the potential to put Resident 1 at risk for suffering continual abuse. Findings: During a review of SOC 341 (Report of Suspected Dependent Adult/Elder Abuse), dated 10/8/24, the SOC 341 indicated, (Resident 1) sent her daughter to pull some money out and her balance was zero. Per resident, the daughter had the bank pull up a camera to see who had used her mothers account and it was (Family Member [FM] 1). She stated (FM 1) was not accepting her phone calls but he finally answered and he confessed to taking her money and apologized. During an interview on 10/21/24 at 3:21 p.m. with Administrator, Administrator stated, I have not followed up. I don ' t know what the conclusion was (of the reported abuse incident's investigation). Normally within five days we have investigation concluded. Administrator stated she was waiting for Social Services Director (SSD) to tell her what the conclusion…

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 ten sampled residents (Resident 1, Resident 2, and Resident 3) were treated with dignity and their privacy respected, when Resident 1, Resident 2, and Resident 3 were not informed in advance of laboratory (lab) orders. This failure had the potential for Resident 1, Resident 2, and Resident 3 ' s dignity and privacy to be violated and resulted in Resident 1 to suffer humiliation. Findings: During an interview on 10/10/24 at 11:23 a.m. with Resident 1, Resident 1 stated on 9/26/24 Resident 1 was sitting in their room when three certified nursing assistants (CNA 1, 2, 3) walk in and hand her a urine cup and told her to pee. Resident 1 stated she asked them why they all three came into her room, she asked them what doctor and what nurse told them to get a urine sample. Resident 1 stated the CNAs stated a licensed vocational nurse (LVN) 1 told the CNAs to get the urine sample. Resident 1 stated she refused to give the urine sample. Resident 1 stated later a registered nurse (RN) 1 came and explained to her 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 consistently carry out physicians ' orders for three of three sampled residents (Resident 4, Resident 5, and Resident 6). These failures had the potential for infections to go unnoticed, for treatments to be ineffective, and possible adverse outcomes for Resident 4, Resident 5, and Resident 6. Findings: During a concurrent interview and record review on 10/10/24 at 2:15 p.m. with Director of Nursing (DON), the Medication Administration Record, (MAR) for Resident 4, Resident 5, and Resident 6, was reviewed and DON confirmed the following: Resident 4 ' s MAR, dated September 2024, the MAR indicated: Change iv (Intravenous-administration of fluids, medications or nutrients directly into a vein) tubing (flexible plastic tube that connects medication and or fluids to a patient iv access site) daily while on iv protonix (medication used to treat gastroesophageal reflux disease [GERD-a digestive disease in which stomach acid or bile irritates the food pipe lining]). -D/C (discontinue) Date- 10/08/2024 1615 (4:15 p.m.) The MAR…

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 one of three sampled residents (Resident 7) urinary catheter (is a tube placed in the body to drain and collect urine from the bladder) collection bag was not touching the floor. This failure had the potential for Resident 7 to develop a urinary tract infection (UTI start when bacteria get into the tube through which urine leaves the body). Findings: During a concurrent observation and interview on 10/28/24 at 2 p.m. with Certified Nursing Assistant (CNA) 4 outside Resident 7 ' s room. Resident 7 urinary catheter collection bag was noted lying on the floor not in dignity bag. CNA 4 confirmed Resident 7 urinary catheter collection bag was lying on the floor not in dignity bag. During a review of the facility ' s policy and procedure (P&P) titled, Catheter -Care of, revised 6/10/21, the P&P indicated, To prevent catheter -associated urinary tract infection . II. Residents with foley catheters will be cared for utilizing the most current CDC (Center for Disease Control) Guidelines to Prevent Urinary Tract Infections…

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 five sampled employees (Director of Nursing [DON]) had the required skills set necessary to ensure residents' safety. This failure had the potential for unqualified staff to supervise the facility ' s residents care. Findings: During a concurrent interview and record review on 9/19/24 at 10:16 a.m. with Administrator, Administrator stated the DON's application should include the education and previous work history with dates of employment and references. Administrator stated the criminal background checks, license checks, and references check were completed prior to the date of hire. The DON employee file was reviewed. The DON's application was noted to be incomplete. There was no education listed and no prior dates of employment or supervisors for previous employers listed. The Administrator confirmed the DON ' s application did not have education listed and no prior dates of employment or supervisors listed for DON ' s previous employers. Administrator stated she did not know if the DON went to an accredited…

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 own policy and procedure (P&P) titled, Abuse-Prevention, Screening, & Training Program, when reference checks were not completed for one of five sampled employees (Licensed Vocational Nurse [LVN] 4). This failure had the potential for the facility ' s residents to be exposed to possible abuse. Findings: During a concurrent interview and record review on 8/30/24 at 11:26 a.m. with Payroll/Accounts Payable (PAP), LVN 4 ' s Employment Application, dated 3/5/24 was reviewed. PAP confirmed LVN 4 had two previous employers and three personal references. LVN 4 ' s Previous/Current Employment Verification, dated 4/12/24, was reviewed. PAP confirmed only one reference check was completed. During a review of the facility ' s P&P titled, Abuse-Prevention, Screening, & Training Program, revised July 2018, the P&P indicated, To address the health, safety, welfare, dignity, and respect of residents by preventing abuse . I. Screening employees: . D. The Facility obtains at least two (2) reference checks from previous 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 follow their policy and procedure (P&P) titled, Abuse Reporting, for one of three sampled residents (Resident 3). This failure resulted in a delay in reporting and had the potential to place all residents at risk for abuse. Findings: During a review of Resident 3 ' s Resident Grievance/Complaint Investigation Report, (RGCIP) dated 8/29/24, the RGCIP indicated, On August 29, 2024 (Resident 3) informed State during an interview that CNA (Certified Nursing Assistant 1) pulled a handful of her pubic hairs . Began investigation and (CNA 1) suspended pending investigation. During an interview on 9/5/24 at 12:29 p.m. with Regional Quality Assurances Consultant (RQAC), RQAC confirmed Resident 3 ' s allegations were not reported timely to California Department of Public Health. RQAC stated the facility should report according to the State and Federal regulations. During a review of the facility ' s P&P titled, Abuse Reporting, revised 1/8/14, the P&P indicated, To ensure compliance with federal and state laws, and regulations…

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 medication carts were secured and accessible to only licensed nursing staff for one of six sampled medication carts. This failure had the potential for unauthorized staff, residents, and visitors, to gain access to medications which had the potential for adverse outcomes. Findings: During an observation on 8/15/24 at 10:40 a.m. at the nurses' station, a medication cart was noted with red lock showing (unlocked). There was no licensed nurse within the line of sight of the cart. Resident 4 was in a wheelchair directly in front of the unlocked medication cart. During a review of Resident 4' s Minimum Data Set, (MDS - an assessment tool) dated 5/3/24, the MDS indicated, Resident 4' s BIMS (Brief Interview for Mental Status) score was 3 (a score of 0-7 indicates the resident is severely impaired cognition). During a concurrent observation and interview on 8/15/24 at 10:43 a.m. with Infection Preventionist (IP), Infront of the medication cart. IP identified the medication cart as medication cart 4. PI…

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 own policy and procedure (P&P) titled, Medication-Administration, when: 1. Medications were not administered as ordered for one of three sampled residents (Resident 1). 2. Medications were not administered timely for one of three sampled residents (Resident 1). These failures resulted a delay in care and unnecessary nerve pain for Resident 1. Findings: 1. During an interview on 8/15/24 at 10:52 a.m. with Resident 1, Resident 1 stated on 7/24/24 she had an appointment and was looking for the nurse so she could get her morning medications. Resident 1 stated she was unable to find the nurse. Resident 1 stated, I skipped all my morning medications and I have neuropathy (nerve pain shooting, stabbing, or burning sensation), and it took 24 hours for my nerves to calmed down. During a review of Resident 1's Minimum Data Set, (MDS - an assessment tool) dated 6/25/24, the MDS indicated Resident 1's BIMS (Brief Interview for Mental Status) score was a 15 (a score of 13 to 15 points indicates the resident is cognitively…

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 for three of three sampled residents (Resident 1, Resident 2, and Resident 3) when: A. Medication given via inhalation (the process of breathing in medication) was shared amongst two residents (Resident 1 and Resident 2). B. Certified Nursing Assistant (CNA) 1 did not conduct hand hygiene per facility policy and procedure. These failures had the potential to spread infection to the residents, staff, and visitors. Findings: A. During a review of Resident 1 ' s MEDICATION ADMINISTRATION RECORD (MAR), dated 8/1/24, the MAR indicated, Resident 1 was on Albuterol Sulfate (medication that opens the air passages to the lungs to make breathing easier) 108 mcg (micrograms – a unit of measurement) two puffs via inhalation every six hours as needed for shortness of breath. During a review of Resident 1 ' s Minimum Data Set (MDS- an assessment tool) under the section BIMS (Brief Interview for Mental Status – an assessment of cognition [mental processes including perception, memory,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide psychotropic medications (medications used for mental health disorders) as ordered upon admission by a physician for one of three sampled residents (Resident 1). This resulted in Resident 1 verbalizing decreased ability dealing with stressors (anything that causes worry or emotional difficulty). Findings: During a review of Resident 1 ' s History and Physical (H&P), dated 6/16/24, the H&P indicated, Resident 1 diagnosis including generalized anxiety (a feeling of worry, unease and/or nervousness), depression (a common and serious medical illness that negatively affects how you feel, the way you think and how you act) and Post Traumatic Stress Disorder (PTSD - a disorder that develops in some people who have experienced a shocking, scary, or dangerous event). During a review of Resident 1 ' s Minimum Data Set (MDS- an assessment tool) under the section BIMS (Brief Interview for Mental Status – an assessment of cognition [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 failed to provide mail to one of three sampled residents (Resident 2) in a manner that would protect his privacy. This failure had the potential for someone to access Resident 2's mail without his consent and potential for violation of residents' rights. Findings: During a review of Resident 1's admission RECORD (AR), dated 7/24/24, the AR indicated, Resident 1 diagnosis including legal blindness, cardiomegaly (enlarged heart) and depression (a constant feeling of sadness and loss of interest). During a review of Resident 1's MDS (Minimum Data Set – an assessment tool) under section BIMS (Brief Interview for Mental Status – an assessment tool for cognition [cognition -the mental processes that take place in the brain, including thinking, attention, language, learning, memory and perception]), dated 6/18/24, the BIMS indicated, Resident 1 had a score of 15 (cognitively intact). During a concurrent observation and interview on 7/25/24 at 2:23 p.m. with Resident 1 in Resident 1's room, Resident 1 had a large clear plastic…

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 fluids within reach for one of three sampled residents (Resident 1). This had the potential for Resident 1 to become dehydrated (a condition that occurs when the body loses too much water and other fluids that it needs to work normally). Findings: During a review of Resident 1's admission RECORD (AR), dated 7/24/24, the AR indicated, Resident 1 diagnosis including legal blindness, cardiomegaly (enlarged heart), chronic kidney disease (a long-term condition where the kidneys do not work as well as they should) and depression (a constant feeling of sadness and loss of interest). During a review of Resident 1's MDS under the section GG (an assessment of the level a care a resident requires), dated 6/18/24, the GG indicated, Resident 1 required set up assistance (assisting prior to and/or following an activity) from facility staff for eating/drinking. During a review of Resident 1's MDS (Minimum Data Set – an assessment tool) under section BIMS (Brief Interview for Mental Status – an assessment tool 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 provide a call light within reach for one of three sampled residents (Resident 1). This failure had the potential for the resident not to be able to call for assistance and result in negative consequences. Findings: During a review of Resident 1's admission RECORD (AR), dated 7/24/24, the AR indicated, Resident 1 diagnosis including legal blindness, cardiomegaly (enlarged heart) and depression (a constant feeling of sadness and loss of interest). During a review of Resident 1's MDS under the section GG (an assessment of the level a care a resident requires), dated 6/18/24, the GG indicated, Resident 1 was dependent on staff for toileting, bathing, oral hygiene, upper and lower body dressing, putting on/taking off footwear and personal hygiene. During a review of Resident 1's MDS (Minimum Data Set – an assessment tool) under section BIMS (Brief Interview for Mental Status – an assessment tool for cognition [cognition -the mental processes that take place in the brain, including thinking, attention, language,…

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 2) received the prescribed nutrients. This failure had the potential for unmet care needs and weight loss. Findings: During a concurrent interview and record review on 7/25/24 at 3:45 p.m. with Director of Nursing (DON 2), DON 2 reviewed Resident 2's Order Details (OD) dated 5/2/24 and 5/17/24, the ODs indicated Resident 2 would receive a standard (regular) portion diet. The Nutrition/Dietary Note, (NDN) dated 5/2/24, was reviewed, the NDN indicated Resident 2 should receive a 4 oz pureed (blended) snack daily. Resident 2's NDN dated 5/2/24, was reviewed, the NDN indicated, Resident 2's diet was upgraded to pureed texture and Resident 2 was to receive G-tube (gastrostomy tube is a tube inserted through the belly that brings nutrition directly to the stomach) bolus feeding (way to give large doses of formula several times a day) twice daily between meals. Resident 2's Documentation Survey Report, (DSR) dated 5/2024, was reviewed. DON confirmed there was seven meals not…

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

Based on observation, interview, and record review, the facility failed to implement their policy and procedure titled, Fall Management Program for one of three sampled residents (Resident 1) when Resident 1 did not have quarterly fall risk evaluations completed. This failure had the potential for Resident 1 to have fall incidents. Findings: During a concurrent observation and interview on 7/9/24 at 11:45 a.m. in Resident 1's room, Resident 1 was lying in bed with a black brace on his right foot, and an orthopedic boot (foot support) under the right side of his bed. Resident 1 stated he went out on pass on Monday (6/24/24) and had a seizure (abnormal electrical activity in the brain that temporarily affects the consciousness, muscle control and behavior) while sitting on a bench at the park and fell off. Resident 1 stated he walked back to the facility and his pain was bad, I couldn't put my weight on it. Resident 1 stated the nurse at the facility assessed him and told him his foot was not swollen and gave him pain medication. Resident 1 stated he has episodes of seizures and take…

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

Based on observation, interview, and record review, the facility failed to implement their policy and procedure (P&P) titled, Out On Pass [OOP], for one of three sampled residents (Resident 1) when Resident 1's out on pass physician order was incomplete. This failure had the potential for Resident 1 to have negative health outcomes such as an unwitnessed seizure (abnormal electrical activity in the brain that temporarily affects the consciousness, muscle control and behavior), fall, and fracture (broken bone). Findings: During a review of Resident 1's Change of Condition (COC), dated 6/25/24 at 7:33 a.m., the COC indicated, Late entry for 6/24/24 At 4:30[p.m.] resident signed for OOP and came back at 8pm accompanied by CNA [certified nursing assistant-unidentified] in stable condition Assisted to the bathroom Resident claimed has heat stroke [severe heat illness] x [times] 2, seizure x3 and fall x2. Assessment done. No redness swelling noted.Resident was able to walk back to bed will continue to monitor. MD (Medical Doctor) aware, recommended neuro (neurological - affecting 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 follow their policy and procedure titled Change of Condition Notification, when the facility did not notify the responsible party of a change of condition for one of three sampled residents (Resident 1). This failure had the potential to result in family not being involved in Resident 1 ' s care. Findings: During a review of Resident 1 ' s eINTERACT Change in Condition Evaluation (COC), dated 6/7/24, the COC indicated Resident 1 was unable to be aroused (awaken), lethargic (lack of energy). Resident 1 was sent to hospital for further evaluation. During a concurrent interview and record review on 7/1/24 at p.m. with Licensed Vocational Nurse (LVN) 1, Nursing Progress Note (NPN), dated 6/7/2024 was reviewed. The NPN indicated, Late entry: Attempted to contact family multiple times with no response. LVN 1 stated, I called the daughter [Family Member/FM], she didn ' t answer and then my shift ended, and I left and never endorsed to next shift. Family was not informed. During an interview on 7/1/24 at 11 a.m. with FM, FM…

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. Seven of 26 sampled residents (Resident 1, Resident 7, Resident 10, Resident 19, Resident 21, Resident 22, and Resident 23) Smoking and Safety (SS) Evaluation identified Resident 1, Resident 7, Resident 10, Resident 19, Resident 21, Resident 22, and Resident 23 ' s ability to hold, light and extinguish a cigarette safely. 2. Ten of 26 sampled residents (Resident 5, Resident 7, Resident 8, Resident 13, Resident 15, Resident 16, Resident 18, Resident 23, Resident 25, and Resident 26) smoking care plans were complete. 3. Four of 26 sampled residents (Resident 5, Resident 16, Resident 23, and Resident 26) SS assessment and care plan for smoking supervision records were accurate. These failures had the potential to result in Resident 1, Resident 5, Resident 6, Resident 7, Resident 8, Resident 10, Resident 13, Resident 15, Resident 16, Resident 18, Resident 19, Resident 21, Resident 22, Resident 23, Resident 25, and Resident 26 experiencing burn injuries and fire, which may affect other residents.…

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

Based on interview and record review, the facility failed to provide a care plan meeting in a timely manner for one of three sampled residents (Resident 1). This failure had the potential to delay or impede aspects of care that Resident 1 required and has the potential to affect Resident 1 ' s ability to safely discharge. Findings: During a review of the facility Resident Grievance/Complaint Investigation Report (RGCIR), dated 4/18/24, the RGCIR indicated, Complainant filed a grievance regarding attempting multiple times to have a care plan meeting with physician present to discuss Resident 1 ' s rights. The RGCIR indicated the following: a. Complainant attempted to have care plan meeting with facility on 2/26/24, but the meeting was canceled by the facility without notification. b. Attempts were made multiple times (no indication on amount) to schedule a care plan meeting with the facility without success. c. A care plan meeting was set by the facility to be conducted on 4/11/24. d. The meeting on 4/11/24 did not have a physician present and therefore was canceled. e. A care plan…

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 1 and Resident 2) activity assessment were completed. This failure had the potential for Resident 1 and Resident 3's activity needs not being met. Findings: During a review of Resident 1's admission Record, (AR) the AR indicated, Resident 1 was admitted on [DATE]. During a review of Resident 1's care plan with the focus on activity involvement, initiated 1/16/23 and revised on 8/30/23. The care plan indicated, The [Resident 1] will express satisfaction with type of activities and level of activity involvement when asked through the review date. During a review of Resident 3's AR, the AR indicated, Resident 3 was admitted on [DATE]. During a review of Resident 3's care plan with the focus on independent activities, initiated 12/20/21 and revised on 12/21/23. The care plan indicated, The [Resident 3] will demonstrate satisfaction with his ability to engage in preferred activities during his stay. 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 licensed nurses were competent to administer medications for three of three sampled residents (Resident 1, Resident 2, Resident 3). This failure resulted in licensed nurses not be competent with passing medications and resulted in the wrong amount of medication given to Resident 2 and had the potential to negative effects. Findings: 1. During a review of Resident 1's MDS (Minimum Data Set - an assessment tool) under the section BIMS [Brief Interview for Mental Status - an assessment tool that determines cognition [the mental processes that take place in the brain, including thinking, attention, language, learning, memory and perception] status], dated 12/21/23, the BIMS indicated, Resident 1 had a score of 15 (cognitively intact). During an interview on 3/12/24 at 1 p.m. with Resident 1, Resident 1 stated he was given the wrong type of narcotic medication when he was in pain (was not able to say what staff member or when this occurred). Resident 1 stated he was given two Clonazepam (medication 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 ensure one of three sampled residents (Resident 2) received services when Licensed Vocational Nurse (LVN) 1 did not administer Resident 2's medications timely. This failure had the potential for adverse effects for Resident 2. Findings: During a review of Resident 2's MDS (Minimum Data Set - an assessment tool) under the section BIMS [Brief Interview for Mental Status - an assessment tool that determines cognition [the mental processes that take place in the brain, including thinking, attention, language, learning, memory and perception] status], dated 1/5/24, the BIMS indicated, Resident 2 had a score of 15 (cognitively intact). During an interview on 3/12/24 at 1:51 p.m. with Resident 2, Resident 2 stated he was overdue for pain medications today (3/12/24) as they (licensed nurses) were supposed to be given to him at 12 p.m. During an observation on 3/12/24 at 2:01 p.m. in Resident 2's room, Licensed Vocational Nurse (LVN) 1 entered the room and handed Resident 2 his medications Norco (narcotic pain…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect one of four sampled residents (Resident 1) from physical abuse. This failure had the potential to result in Resident 1 being seriously harmed and affect her psychosocial well-being. Findings: During a review of the facility's Investigative Report (IR), dated 3/7/24, the IR indicated, Resident 1 was struck in the head by Resident 2. The IR indicated, On 3/2/24 at approx. [approximately] [8:30 a.m.] [Resident 1] was slapped on the face and pushed by [Resident 2] while at the ' C' wing nurse's station. Per Licensed Nurse [not identified], while giving [Resident 1] her medications at the nurse's station [Resident 2] suddenly came to the nurse's station and ' attacked' [Resident 1]. She [Licensed Nurse] added ' it happened so fast'. When interviewed, [Resident 2] stated that she was having ' bad dreams'. In another interview with [Resident 2] stated that [Resident 1] is stealing her identity. During a review of the facility's IR, dated 3/13/24, 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 implement their policy and procedure on theft and loss for one of three sampled residents (Resident 3). This failure resulted in the loss of Resident 3's belongings and had the potential to affect other residents. Findings: During an interview on 3/20/24 at 8:39 a.m. with Complainant, Complainant stated Resident 3 was sent from the facility to the hospital (no specific date given) and had not been doing well. Complainant stated she went to the facility to gather Resident 3's belongings and the Facility Marketer (FM) told her to go ahead and go into his room and get his belongings. Complainant stated she was not asked to sign out Resident 3's belongings or do anything that would indicate all of Resident 3's belongings were accounted for. Complainant stated she believed Resident 3 had his cell phone and cell phone charger missing but was not able to verify since Resident 3 was ill. During an interview on 3/20/24 at 3:44 p.m. with FM, FM stated she had taken Complainant to Resident 3's room to pick up Resident 3's belongings…

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 discharge plan of care according to their policy and procedure for one of four sampled residents (Resident 3). This failure had the potential for harm and/or lack of appropriate services to be provided to Resident 3 upon discharge. Findings: During an interview on 3/20/24 at 8:39 a.m. with Complainant, Complainant stated Resident 3 is part of a federally funded group [FFG] that assist individuals in transitioning back to independent living. Complainant stated the FFG had contacted Resident 3's facility on several occasions to obtain records and discuss the plan for discharge but have not had any response. Complainant stated prior to entering the facility Resident 3 was already set up with housing and an in-home-caregiver but was in danger of losing both due to being unable to get the required documents from the facility. Complainant stated the FFG required a facility discharge care plan that indicated Resident 3 was able to return 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two of five sampled residents (Resident 1 and Resident 2) were provided adequate showers or bath. This failure had the potential for Resident 1 and Resident 2's comfort and cleanliness to be affected. Findings: During a review of Resident 1's admission Record, (AR) the AR indicated, Resident 1 was admitted on [DATE], with diagnoses included muscle weakness, difficulty walking, and need for assistance with personal care. During a review of Resident 2's Minimum Data Set, (MDS - an assessment tool) dated 2/2/24, the MDS indicated, Resident 2's BIMS (Brief Interview for Mental Status) score was 13 (13 to 15 points indicates resident is cognitively intact). During an interview on 3/7/24 at 1:42 p.m. with Resident 2, Resident 2 stated she does not receive two showers a week. She stated sometimes she only gets one shower a week and sometimes the certified nursing assistants (CNA) do not come to give her a shower. Resident 2 stated she does not 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two of five sampled residents (Resident 1 and Resident 3) nutritional needs were assessed timely. This failure had the potential for Resident 1 and Resident 3's nutritional needs not to be met. Findings: During a concurrent interview and record review on 3/29/24 at 4:40 p.m. with Registered Dietitian (RD), RD stated initial nutritional assessments are completed within seven days of admission. RD reviewed Resident 1's admission Record, (AR). RD confirmed Resident 1 was admitted on [DATE], with a diagnosis of abnormal weight loss. RD reviewed Resident 1's medical record and confirmed there was no nutritional assessment completed. RD reviewed Resident 3's AR. RD confirmed Resident 3 was admitted [DATE], with a diagnosis of type 2 diabetes mellitus (condition in which the body has trouble controlling blood sugar and using it for energy). RD reviewed Resident 3's medical record and confirmed no nutritional assessment was completed. 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 follow their policy and procedure (P&P) on controlled medication storage for four of six medication carts. This failure had the potential for residents' inaccurate controlled medication documentation and potential for unidentified controlled medication diversion. Findings: During a concurrent interview and record review on 3/29/24 at 1:44 pm with LVN (Licensed Vocational Nurse) 1, the facility's Controlled Drugs – Count Record (CDCR) in medication cart 4, dated March 2024 was reviewed. The CDCR indicated the following dates did not have licensed nurses' signatures for acknowledging they counted the controlled drugs on hand: 1. 3/1/24, AM shift off going nurse 2. 3/1/24, PM shift oncoming and off going nurse 3. 3/5/24, PM shift oncoming and off going nurse 4. 3/5/24, NOC shift off going nurse 5. 3/6/24, AM shift oncoming nurse 6. 3/6/24, PM shift oncoming and off going nurse 7. 3/7/24, AM shift oncoming nurse 8. 3/7/24, PM shift off going nurse 9. 3/10/24, AM shift oncoming nurse 10. 3/10/24, PM shift off going nurse 11.…

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 MDS (Minimum Data Set - assessment tool) quarterly (every three months) assessments were completed within 14 days after the ARD [Assessment Reference Date - the specific end point of look-back periods in the MDS assessment process] for one of four sampled residents (Resident 1). This failure had the potential for the delay in assessment and development of Resident 1's individualized care plan. Findings: During a concurrent interview and record review on 3/29/24 at 11:29 p.m. with Minimum Data Set Coordinator (MDSC), Resident 1's MDS Nursing Home Quarterly dated February 23, 2024 (ARD) was reviewed. Resident 1's MDS Nursing Home Quarterly indicated it was completed on 3/28/24 (21 days overdue). MDSC stated the MDS quarterly assessment was not completed within 14 days. During a review of the facility's Resident Assessment Instrument Manual (RAI), dated October 2023, the RAI indicated, The MDS completion date must be no later than 14 days after the ARD (ARD + 14 calendar days).

Based on interview, and record review, the facility failed to ensure fall risk evaluation were completed quarterly (every three months) for two of four sampled residents (Resident 1 and Resident 2). This failure had the potential to place Resident 1 and Resident 2 at risk for further falls. Findings: During a review of Resident 1's SBAR (Situation, Background, Assessment, Recommendation), dated February 28, 2024, the SBAR indicated, CNA [Certified Nursing Assistant] found [Resident 1] on the restroom floor. During a concurrent interview and record review on 3/29/24 at 11:05 am with the Director of Nursing (DON), Resident 1's Fall Risk Evaluation, dated June 6, 2021 (initial evaluation) was reviewed. The Fall Risk Evaluation indicated Resident 1 is At Risk for falls. DON stated Resident 1 is already at risk for falls on the initial assessment because Resident 1 had a fall at home. During a concurrent interview and record review on 3/29/24 at 11:05 a.m. with DON, Resident 1's Fall Risk Evaluation, dated February 28, 2024 and September 21, 2023 were reviewed. DON was unable to find…

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 on abuse for two of four sample residents (Resident 1 and Resident 2) when: 1. Resident 1 and Resident 2 were not monitored for psychosocial well-being after an altercation incident. 2. The Administrator did not coordinate and implement the facility ' s abuse policy and ensure monitoring, investigation, and documentation of the incident were completed. These failures had the potential to delay the investigation and place Resident 1 and Resident 2 at risk for suffering continuous psychosocial harm. Findings: 1. During a review of SOC-341 (State of California form 341 – form used to report suspected abuse), dated March 7, 2024, the SOC-341 indicated, I [Licensed Vocational Nurse/LVN 1] heard screams coming from room [Resident 1 and Resident 2 ' s room] and I rushed in to find both residents hitting each other. During an interview on 3/12/24 at 1:09 pm with Resident 1. Resident 1 stated, She [Resident 2] kicked me in the leg. Look, I have bruises on my leg. I hit her [Resident 2]…

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

Based on observation, interview, and record review, the facility failed to: 1. Document notification of the physician and responsible party (RP-resident's decision-maker) of an incident for two of four sample residents (Resident 1 and Resident 2) when Resident 1 and Resident 2 had an altercation incident. 2. Document an assessment of injuries and change of condition for one of four sample residents (Resident 2) after an altercation incident. These failures had the potential to place Resident 1 and Resident 2 at risk for suffering continuous physical or psychosocial harm from the altercation incident. Findings: 1. During a review of SOC-341 (State of California form 341 – form used to report suspected abuse), dated March 7, 2024, the SOC-341 indicated, I [Licensed Vocational Nurse/LVN 1] heard screams coming from room [Resident 1 and Resident 2 ' s room] and I rushed in to find both residents hitting each other. During a concurrent observation and interview on 3/12/24 at 1:09 pm with Resident 1 in Resident 1 ' s room. Resident 1 stated, She [Resident 2] kicked me in the leg. Look I…

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

Based on observation, interview, and record review, the facility failed to report to the Department an unobserved fall with fracture for one of three sampled residents (Resident 1). This failure resulted in a delay in the investigation of the unwitnessed fall and injury. Findings: During a concurrent observation and interview on 1/22/24 at 4:25 p.m. with Resident 1, Resident 1 had a cast on his left arm. Resident 1 stated he slipped and fell on water that was leaking from the toilet while he was attempting to use the restroom unassisted. During a review of Resident 1 ' s Care Plan (CP), revised 9/15/23, the CP indicated, [Resident 1] is alert and able to make needs known with BIMS [Brief Interview for Mental Status-exam used to determine a person ' s level of cognition or understanding] of 15/15 [15 is the highest score, indicates the person has no impairment in cognition]. During an interview on 2/26/24 at 12:12 p.m. with Director of Nursing (DON), DON stated, We don ' t know exactly what happened because Resident 1 changed his story after the incident to say he fell. DON 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 care plan was followed for one of three sampled residents (Resident 1). This failure resulted in assessments, monitoring, and notifications not being done after an allegation of abuse. Findings: During a review of the Report of Suspected Dependent Adult/Elder Abuse (completed by the facility) (SOC 341), dated 1/30/24, the SOC indicated, [Resident 1] had a previous alleged incident with the same employee, which an SOC was submitted. Today he alleged that the maintenance was blowing leaves off the roof of building, and was purposely blewing (sic) them on [Resident 1] out in the courtyard.Reported types of abuse.other. During a review of Resident 1 ' s Care Plan (CP), dated 1/21/24, the CP indicated, 1/30/24 [Resident 1] claimed a staff member purposely blowing leaves on him.Intervention.MD (physician).notified.skin assessment.Monitor/assess for s/s (signs and symptoms) of pain or discomfort. During a concurrent interview and record review, on 2/6/24 at 12:20 p.m., with Director of Nursing (DON), Resident 1 ' s…

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

Based on interview and record review, the facility failed to provide suprapubic catheter (a tube inserted through the stomach surgically in order to drain the bladder of urine) care for one of three sampled residents (Resident 1). This failure had the potential for infection to occur and lead to negative consequences up to and including death. Findings: During an interview on 12/4/23 at 10:49 a.m. with Complainant, Complainant stated Resident 1 had a history of recurrent urinary tract infections causing Resident 1 to be severely weak. Complainant stated on 11/16/23, she visited Resident 1 and had a meeting with the facility and reported Resident 1's suprapubic catheter was not being cleaned. Complainant stated the facility reassured her they would clean Resident 1's suprapubic catheter as ordered by the physician. Complainant stated she visited Resident 1 on 11/21/23, and Resident 1 informed her the facility was still not cleaning his suprapubic catheter. Complainant stated Resident 1's suprapubic insertion site insertion site was smelly and reddened. Complainant stated she visited…

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 1) was free from verbal abuse. The failure resulted in Resident 1 being verbally abuse by staff. Findings: During an interview on 10/16/23, at 2:16 p.m. with Director of Nursing (DON), DON stated, the resident went to the facility kitchen with his food tray. Resident 1 in his wheelchair opened the kitchen door and threw his meal tray to the kitchen floor and an argument started between [NAME] 1 and Resident 1. Resident 1 and [NAME] 1 were separated. During an interview on 10/16/23, at 3:20 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated, she was walking to the dining room to get something for a resident, CNA 1 was standing by the kitchen entrance when she saw Resident 1 coming down the hallway with his meal tray. CNA 1 stated she attempted to assist the resident with his tray to which the Resident 1 stated no. He then started cursing at the kitchen staff and she witnessed him toss his meal tray into the kitchen. During an interview on 12/12/23, at 1:24…

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 and procedure titled Unusual Occurrence Reporting when the facility did not report timely within 24 hours when one of three sampled residents (Resident 1) went missing after not returning from an outing. This failure had the potential to place Resident 1 at risk for injuries or neglect. Findings: During a concurrent interview and record review on 10/20/23, at 10:43 a.m. with Licensed Vocational Nurse (LVN) 1, facility ' s Out on Pass (OOP) binder, dated 10/1/23 – 10/31/23 was reviewed. The OOP binder indicated, Patient 1 did not have a signature on 10/3/23 when she left the facility. LVN 1 was unable to provide documentation of Resident 1 going out on pass. LVN 1 stated, the facility ' s process for residents going out on pass was to sign the OOP Binder and for the nurse assigned to the the resident, to co-sign on the OOP Binder. During a review of Resident 1 ' s admission Record (AR), dated 10/11/23, the AR indicated, Resident 1 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure three of 52 sampled residents' (Resident 13, Resident 90 and Resident 102) call lights were accessible and answered timely when: 1. Resident 13's call light was not within reach. 2. Resident 90's call light was not answered promptly. 3. Resident 102 was not provided a call light that he was able to activate. These failures had the potential for Resident 13, Resident 90 and Resident 102, not being assisted with their activities of daily living (ADL). Findings: 1. During an observation on 11/13/23, at 8:51 a.m. in Resident 13's room, Resident 13 was lying in bed with the head of the bed partially raised. Resident 13's right hand was contracted, unable to reach the call light. Resident 13's neck was contracted, bent to the left side. Resident 13's call light was clipped to the curtain beside Resident 13's bed. The call light was out of Resident 13's reach. During a concurrent observation and interview on 11/13/23 at 8:54 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 three of 13 sampled residents' (Resident 99, Resident 106, and Resident 58) had reasonable access to use a telephone with privacy. This failure resulted in residents not having their rights to privacy while making telephone calls. Findings: During a resident council meeting interview on 11/14/23 at 10:00 a.m. with Resident 99, Resident 99 stated, We have to use the phones at the nurse's station. There is no privacy, they don't have wireless phones. During a review of Resident 99's Minimum Data Set (MDS-assessment tool), dated 9/25/23, the MDS indicated, Resident 99 had a BIMS (Brief Interview for Mental Status Score) of 12 (score of 8-12 means moderate impairment). During a resident council meeting interview on 11/14/23 at 10:00 a.m. Resident 106 stated, They do not let me have a phone call. During a review of Resident 106's MDS, dated 8/31/23, the MDS indicated, Resident 106 had a BIMS of 12. During an interview on 11/16/23 at 9:26 a.m. with Resident 58, Resident 58 stated, I don't have a phone, I…

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

Based on interview and record review, the facility failed to develop three of four sampled residents' (Resident 3, Resident 20, and Resident 102) individualized activities care plans. These failures had the potential for Resident 3, Resident 20, and Resident 102, not receiving activities specific to their preference or choice. Findings: During an interview on 11/14/23 at 10:43 a.m. with Resident 20, Resident 20 stated he does not go to activities because they are boring and are activities for children. Resident 20 stated they do not have activities for residents who are mentally competent. Resident 20 stated he would go to activities if there were more intellectual games to play, he would enjoy playing dominos and chess. During concurrent interview and record review on 11/16/23 at 9:00 a.m. with Director of Activitiess (DOA), Resident 20's Activities Care Plan (ACP), was reviewed. DOA stated Resident 20's ACP was not individualized, did not have his interests (intellectual games, dominos, and chess) identified and had not been updated for over a year. During a review of Resident…

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

Based on observation, interview, and record review, the facility failed to implement infection control practices when: 1. Residents were not assisted with hand hygiene before meals in the dining room. 2. A used syringe (medical instrument for injecting or drawing off liquid) in Resident 84's room was not disposed into a designated container. These failures had the potential to result in spread of infection to residents, staff, and visitors. Findings: 1. During an observation on 11/13/23, at 11:35 a.m. in the dining room, several residents entered the dining room, propelling themselves in wheelchairs, touching their wheelchair wheels. Residents were seating themselves at the tables in the dining room. Staff were observed serving drinks to residents. Residents were not observed performing hand hygiene or being offered or reminded by staff to perform hand hygiene prior to their meal being served. During an interview on 11/13/23, at 11:41 a.m. with Certified Nursing Assistant (CNA 1), CNA 1 stated residents were not offered to wash or sanitize their hands in the dining room. During 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 ensure four of 52 sampled residents' (Resident 235, Resident 131, Resident 236, and Resident 238): 1. Physician's orders were followed for the use of an incentive spirometer (handheld medical device used to help patients improve the functioning of their lungs) for Resident 235, Resident 131, and Resident 236. These failures had the potential to result in respiratory (breathing) complications. 2. Resident 238 was identified before administering medications. This failure had the potential for administering medications to the wrong resident. Findings: 1. During a review of Resident 235's Order Summary Report (OSR), dated 11/3/23, the OSR indicated, Incentive Spirometer 1 dose 10 breaths Q [every] 8 H [hours] While awake. During a review of Resident 235's Minimum Data Set (MDS - screening assessment tool) dated 11/10/23, the MDS indicated BIMS (Brief Interview for Mental Status) was 12 (8-12 moderate impairment). During a concurrent observation and interview on 11/14/23 at 9:48 a.m. in Resident 235's room, 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 ensure one of eight sampled resident's (Resident 13) was assisted with oral care. This failure resulted in Resident 13 having dental issues and/or tooth decays. Findings: During an observation on 11/13/23, at 8:51 a.m., in Resident 13's room, Resident 13's teeth were observed to have plaque (a sticky film that coats teeth and contains bacteria. Dental plaque can damage a tooth and lead to tooth decay or tooth loss. Regular brushing can help prevent plaque) build up and yellowish discoloration. During a concurrent observation and interview on 11/15/23 at 9:02 a.m., with Licensed Vocational Nurse (LVN) 3, in Resident 13's room, LVN 3 verified Resident 13's teeth had plaque build up and yellowish discoloration. During a review of Resident 13's Care Plan (CP), undated, the CP indicated Resident 13 had an ADL (activities of daily living) self-care performance deficit related to functional quadriplegia (complete immobility due to severe disability or a medical condition without injury to the brain or spinal cord),…

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 five sampled resident's (Resident 235) activity assessment was completed. This failure had the potential for Resident 235's activity needs not being met. Findings: During an interview on 11/14/23 at 9:46 a.m. in Resident 235's room, Resident 235 stated no one has come into his room and talked to him regarding any activities. During a review of Resident 235's admission Record (AR), dated 11/15/23, the AR indicated, Resident 235 was admitted on [DATE]. During a concurrent interview and record review on 11/15/23 at 2:07 p.m. with Nurse Consultant (NC), Resident 235's medical record was reviewed. NC stated there was no activity assessment completed and should have been completed within 7 days of admission [DATE]). During a review of the facility's policy and procedure (P&P) titled, Activity Assessment/Care Plan dated November 01, 2013, the P&P indicated, Purpose To assess each resident's preferences for customary routine and activity…

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 assess one of one sampled resident (Resident 84) for safe use of cigarette lighters. This failure had the potential to result in accidents and place all residents' safety at risk. Findings: During an observation on 11/13/23 at 9:45 a.m. in Resident 84's room, two cigarette lighters were on top of Resident 84's bedside table. During an interview on 11/13/23 at 10:10 a.m. with Director of Nursing (DON), and Assistant Director of Nursing (ADON), DON stated Resident's smoking materials should be kept at the nursing stations. ADON stated Resident 84 have not been assessed for safe handling of smoking materials. During a concurrent interview and record review on 11/15/23 at 1:33 p.m with ADON, Resident 84's Care Plans were reviewed. ADON stated Resident 84 had no care plan for the safe storage of smoking materials. During a review of the facility's policy and procedure (P&P) titled, Smoking Residents dated 8/18/23, the P&P indicated, The IDT (interdisciplinary team) will develop and individualized plan of 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 ensure two of seven sampled residents' (Resident 131 and Resident 239) were free from medication error rate of greater than five percent (%) when two medication errors occurred within 37 opportunities resulting in a 5.41% error rate. This failure had the potential for Resident 131 and Resident 239 not receiving the full therapeutic effects of the medication and potential for adverse health outcomes. Findings: During an observation on 11/15/23 at 8:13 a.m. in Resident 131's room, Licensed Vocational Nurse (LVN) 2 obtained Resident 131's blood pressure reading and stated to Resident 131 her blood pressure (measure of circulating blood against the walls of vessels) was 103/59 (normal blood pressure range 120 [systolic]/80 [diastolic]). During an observation on 11/15/23 at 8:20 a.m. in Resident 131's room, LVN 2 administered half tablet of Entresto (medication to treat blood pressure) 49-51 mg (milligram - a unit of measure). During a review of Resident 131's Order Summary Report (OSR), dated 11/15/23, the OSR…

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 52 sampled resident's (Resident 106) meal preferences were honored. This had the potential to result in unmet nutritional needs. Findings: During an observation on 11/13/23 at 12:12 p.m. in the dining room (DR), Resident 106 was observed sitting with three other residents having lunch in the DR. During a concurrent interview and record review on 11/13/23 at 12:12 p.m. with Resident 106, Resident 106's Meal Tray Ticket (MTT), dated 11/13/23 was reviewed. The MTT indicated, Resident 106 disliked pork. Resident 106 stated he does like pork and stated he had been telling the kitchen staff for more than a year to change his MTT. Resident stated, They don't listen. During a concurrent interview and record review on 11/15/23, at 10:15 a.m. with the Registered Dietitian (RD), Resident 106's MTT, dated 11/13/23 was reviewed. The MTT indicated Resident 106 disliked pork. RD stated she would make the change in Resident 106's MTT. During a review of the facility's policy and procedure (P&P) titled, Dietary…

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 one of one sampled resident (Resident 104) a therapeutic fortified (added calories) diet according to physician's order. This failure had the potential for not meeting Resident 104's nutritional needs. Findings: During a review of Resident 104's Meal Tray Ticket (MTT), dated 11/13/23 at 12:14 p.m., the MTT indicated, NAS (no added salt) Fortified Regular Allergies: Chocolate, Dairy Products, Melons Including Watermelon, Nuts. During a concurrent observation and interview on 11/13/23 at 12:16 p.m. with Registered Dietitian (RD) in the main dining room, Resident 104's meal plate contained a meatball sandwich without cheese and a serving of green beans. RD stated the fortified item for the meal is cheese and Resident 104's plate does not have cheese because she has an allergy to dairy products. When asked what alternative fortified item was provided, RD stated she would need to check. RD returned with a small container of melted butter and stated, This [melted butter] is the alternate fortified item. RD…

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 and procedure on Advance Directives (AD – a written instruction such as a living will or durable power of attorney for health care recognized under State law, relating to the provision of future health care decisions) for one of three sampled residents (Resident 1), when facility staff spoke to Resident 1's family member not appointed as a healthcare agent regarding financial transactions. This failure resulted in violating Resident 1's rights for not honoring his legal wishes as indicated in his AD. Findings: During a review of Resident 1's admission Record (AR), (undated), the AR indicated, Resident 1 was admitted on [DATE] with diagnoses included cerebral infarction (disrupted blood flow to the brain) and hemiparesis (right-sided weakness). During a review Resident 1's History and Physical Examination (HPE), dated 6/21/23, the HPE indicated, Resident 1 had the capacity to understand choices and make healthcare decisions. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement their policy on abuse for one of three sampled residents (Resident 1). This failure had the potential for abuse to continue and for other residents to potentially be abused. Findings: During an interview on 9/7/23 at 10:52 a.m. with Resident 1, Resident 1 stated Licensed Vocational Nurse (LVN) 1 had threatened to kick him out of the facility for not minding his own business around the date of 8/27/23. During an interview on 9/7/23 at 11:56 a.m. with Administrator, Administrator stated he was not aware of an allegation of abuse by Resident 1 regarding LVN 1. During an interview on 10/10/23 at 9:01 a.m. with LVN 1, LVN 1 stated sometime in August (could not recall the exact date) Resident 1 had screamed out that everyone in the facility was abusing him. LVN 1 stated Resident 1 had called her a [explicit name] and told her to leave his room. LVN 1 stated she told the Director of Nursing (DON) about Resident 1 stating everyone was abusing him 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.