Kindred Hospital Brea D/P SNF

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to ensure a copy of the resident's advanced directive was available in their medical record for one of one final sampled resident (Resident 13) investigated for Advanced Directives. * The facility failed to obtain a copy of Resident 13's advance directive and place in the resident's medical record. This failure had the potential for the resident's wishes for medical care and choice of healthcare agent not being communicated effectively in the event the resident was unable to make her own medical decisions. Findings: Medical record review for Resident 13 was initiated on 1/28/26. Resident 13 was admitted to the facility on [DATE]. Review of Resident 13's H&P examination dated 9/2/25, showed the resident had the capacity to understand and make healthcare decisions. Review of Resident 13's POLST dated 9/3/25, showed the resident did not have an advanced directive (a legal document that outlines your preferences for medical treatment and appoints 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 medical record review, the facility failed to ensure the appropriate bed hold process was followed for one of one sampled resident (Resident 42) reviewed for bed hold. * Resident 42's bed hold was cancelled prior to the end of the seven-day bed hold. This failure resulted in Resident 42 not being allowed to return to the facility when Resident 42 was transferred to the acute care hospital. Findings: On 1/23/26, CDPH received a complaint regarding Resident 42's bed hold being cancelled prior to the end of the seven-day bed hold. Review of the facility's P&P titled SAU (Subacute Unit) Transfer, Discharge, Bed-hold Procedure reviewed 9/2025 showed at the time of transfer/discharge, the patient and family member or legal representative are given a written notice of the bed-hold policy that specifies the duration of the bed hold and readmission criteria after the bed-hold period ends. In addition, the policy showed the SAU allows a patient whose hospitalization or therapeutic leave exceeds the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the resident or resident's representative was provided with the required information when the resident was transferred and/or discharged for two of three sampled residents (Residents 39 and 42) reviewed for transfer and discharge. * The facility failed to ensure Resident 39 and/or their representative were notified of the transfer and reasons for the transfer in writing when the resident was discharged to an Assisted Living Facility. * The facility failed to provide facility's bed hold policy and notice of transfer when Resident 42 was transferred to the acute care hospital and was not permitted to readmit to the facility. These failures resulted in the interested parties not having the complete information related to the discharge and transfer process. In addition, this failure had the potential for the resident and/or their representative of not knowing about the appeals process and the circumstances of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to develop detailed resident centered care plans for two of 12 final sampled residents (Residents 1 and 22).* The facility failed to ensure a care plan was developed to address the use of insulin (medication to lower blood sugar) for Residents 1 and 22.These failures posed the risk of not providing appropriate, consistent, and individualized care to these residents.Findings: Review of the facility's P&P titled Care Plans released 11/2022 showed a comprehensive care plan is developed consistent with the patients' conditions, risks, needs, behaviors, preferences and with standards of practice including measurable objectives, interventions/services, and timetable to meet the patient's needs as identified in the patient's assessment or as identified in relation to the patient's response to the interventions or changes in the patient's condition, reflects the patient's needs and preferences and align with the patient cultural…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the individualized and ongoing activity program to meet the needs and interests for one of one final sampled resident (Resident 18) reviewed for activities. * The facility failed to provide documentation Resident 18 received meaningful activities from the facility for December 2025 and January 2026. This failure had the potential to affect the resident's psychosocial well-being.Findings: Review of the facility P&P titled Activity Programs dated 11/2022 showed the facility to provide based on the comprehensive assessment and care plan and the preference of each patient, an ongoing program to support patients in their choices of activities, both group and individual activities and independent activities, designed to provide each patient to have a meaningful life by supporting his/her domains of well-being. Activities are individualized and customized based on the patient previous life style (occupation,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and interview, the facility failed to ensure one of four sampled residents (Resident 2) reviewed for pressure injuries received the care and services to heal the resident's pressure injuries. * Resident 2's special mattress was not functioning properly. In addition, there was no physician's order for the use of the special mattress. This failure posed the risk of delay in healing for Resident 2's pressure injuries. Findings: Medical record review for Resident 2 was initiated on 1/28/26. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's H&P examination dated 10/8/25, showed Resident 2's diagnoses included Stage IV pressure injuries to her sacrum and left hip. Further review of the H&P showed Resident 2 had the capacity to understand choices and make health care decisions. Review of Resident 2's January 2026 Physician Order Sheet dated 1/29/26, showed a a diagnosis of pressure ulcer of sacral region, Stage IV dated 10/7/25. Further review of the Physician Order Sheet…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of one nonsampled resident (Resident 27) reviewed for limited range of motion received the appropriate treatment and services. * The RNA services and instructions for Resident 27 were not completed. This failure had the potential to result in the decline in Resident 27's range of motion which could lead to further deterioration in the resident's physical well- being.Findings: Review of the facility's P&P titled Guideline-Restorative Services dated 8/2025, showed restorative techs are hired , trained, and employed by the rehabilitation department. The restorative plan for each patient is developed through a collaborative effort between nursing and therapy. Once completed, the restorative plan of care is incorporated into nursing plan of care. Patient may receive services up to seven days a week. Patient placed in the restorative program may meet one or more of the criteria from the list which included patient who…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the proper pain assessment, implementation of non pharmacological interventions, and appropriate pain medication administration per physicians' orders for two of five residents (Residents 7 and 13) reviewed for unnecessary medications. * Resident 7's admission pain assessment was incomplete. The resident did not have physicians' orders to appropriately address and treat the resident's pain level, and the facility failed to document and implement NPI for pain management. * Resident 13 did not have documented use of non pharmacological interventions for pain management. These failures had the potential to put the residents at risk for ineffective pain management and adverse effects related to the use of unnecessary pain medications.Findings: Review of the facility's Subacute Unit (SAU) Procedure - Pain Management P&P reviewed May 2025 showed: - Upon admission, nursing will perform an initial pain assessment to include…

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

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the nursing staff were competent. * The facility failed to ensure LVN 2 diluted the crushed medications before administering them via GT for one of two nurses observed for GT medication administration. * The facility failed to ensure the IP/DSD was aware about the VIS (Vaccination Information Sheet) and the need to provide the residents and and their representative with the education on risks, benefits, and potential side effects from the influenza, pneumococcal, and COVID-19 vaccinations. These failures had the potential for a partial dose being administered or the tube becoming clogged. In addition, the failures had the potential for the residents and/or their representatives in the facility of not being informed of the updated influenza, pneumococcal, and COVID-19 vaccinations, the benefits, risks, and potential side effects of the influenza, pneumococcal, and COVID-19 vaccinations to make an informed decision.Findings: Review of the facility's P&P titled Medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to follow-up on the Pharmacist Consultant's Medication Regimen Review (MRR) recommendations for one of five residents investigated for Unnecessary Medications. * The facility failed to provide an in-service education to the staff per the Pharmacist Consultant's Report recommendation to remind the staff of administering/holding medications within the ordered parameters. This failure resulted in the continued deficient practice of midodrine (medication to treat low blood pressure) being administered to the residents (Residents 7 and 13) outside of the ordered parameters. Findings:Review of the facility's Medication Regimen Review (MRR) P&P revised 6/1/24, showed the consultant pharmacist will conduct monthly MRR and make recommendations, which will be provided to the facility, and the facility will act upon the recommendations. Review of the facility's MRR binder, showed a Pharmacist's Consultation Report for 12/3-4/25. 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, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 32%. Two of five licensed staff (LVN 2 and RN 4) were found to have made errors during the medication administration observations.* LVN 2 failed to administer the complete dose for four of Resident 13's crushed medications when medication residues were observed in the medication pouches. * RN 4 failed to administer the complete dose for four of Resident 18's crushed medications when the medication residues were observed in the medication pouches and cups. These failures had the potential to negatively affect the residents' health.Findings: 1. On 1/29/26 at 0821 hours, a medication administration observation for Resident 13 was conducted with LVN 2. LVN 2 was observed crushing the following medications and then transferring them to the individual medication cups to be administered via GT:-hydrocodone 5 mg - acetaminophen 325 mg tablet (controlled medication for pain relief)-cetirizine…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to ensure complete and accurate medical records for one of five final sampled residents reviewed for unnecessary medications (Resident 7), and one of three final sampled residents reviewed for pressure injuries (Resident 4). * Resident 7's documented pain level for each shift did not show the resident's highest pain level for the shift on multiple shifts.* Resident 3's Stage 4 pressure injury was incorrectly documented on their weekly assessment as a DTI (Deep Tissue Injury). These failures resulted in inaccurate medical records for Residents 4 and 7. Findings: 1. Medical record review for Resident 7 was initiated on 1/28/26. Resident 7 was admitted to the facility on [DATE]. Review of Resident 7's Physician Order Sheet for January 2026 showed a physician's order dated 12/11/25, to monitor for pain every shift on a scale of 0 to 10 (0 being no pain, and 10 being the worst pain). a. Review of Resident 7's TAR for December 2025 showed the 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 facility document review, the facility failed to maintain the essential equipment in a clean, sanitary, and safe operating condition for two of two sinks (Sinks 1 and 2) inspected. * The facility failed to ensure Sink 1 was working properly. * The facility failed to ensure Sink 2 had no missing knobs on the faucet. These failures resulted in the essential equipment not in operating condition and not to function in the way it was intended, which could expose the residents to unsafe practices.Findings: Review of the facility's Patients Diet List dated 1/28/26, showed a total of 13 out of 36 residents received food prepared in the facility's kitchen. On 1/28/26 at 0750 hours, a tour of the facility's kitchen and concurrent interview was conducted with Dietary Manager 1. When asked about the dishwashing area, Dietary Manager 1 stated Sink 1 was not working. In addition, Sink 2's faucet was observed with missing faucet knobs. Dietary Manager 1 verified the findings. On 1/28/26 at 0817 hours, an interview was conducted with the Engineering Manager.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, closed medical record review, and facility P&P review, the facility failed to meet the professional standards of care for one of three sampled resident (Resident 1) reviewed for change of condition. * RT 1 failed to follow the professional standards of care when he attended Resident 1's change of condition. This failure posed the risk of not providing the appropriate and necessary care and services to the resident during a change of condition.Findings: Review of the facility's P&P titled Quality of Care released on 10/2022 showed the Subacute Unit (SAU) identifies and provides needed care and services that are resident centered, in accordance with the resident's preferences, goals for care, and professional standards of practice that will meet each resident's physical, mental, and psychosocial needs and ensure each resident receives necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being consistent with the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, closed medical record review, and facility P&P review, the facility failed to ensure the quality care and services were provided for one of five sampled residents (Resident 1). * The facility failed to obtain the physician's orders and informed consents prior to the beside debridement (the medical removal of dead, damage, or infected tissue to improve the healing potential of the remaining tissue) for Resident 1's scrotal and perineal/perianal wounds. In addition, the facility failed to ensure the wound assessments were completed after the bedside debridement. These failures had the potential for Resident 1 to not receive the necessary care and services to maintain the resident's highest physical well-being.Findings: Review of the facility's P&P titled CORE: Conservative Sharp Wound Debridement released 6/2021 showed conservative sharp wound debridement:a. May require more than one session (serial based on the needs of the patient and the characteristics of the wound).c. Each debridement…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services related to pressure injuries (areas of damaged skin caused by staying in one position for a long time which reduces blood flow to the area and causes the skin to die and develop a sore to promote wound healing) were provided to three of three sampled residents (Residents 1, 2, and 3) reviewed for wound management. * The facility failed to ensure the physician was informed and a change of condition was initiated when there was an increase in the wound size and necrotic tissue for Resident 1's sacrococcyx (fused bone at the very end of the spine) pressure injury. * The facility failed to ensure the LAL mattress setting was consistent with Residents 2 and 3's weight. These failures posed the risk for complications and delayed wound healing.Findings: Review of the facility's P&P titled CORE: Clinical Guidelines for Pressure Injury released 6/2022 showed each resident should…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the least restrictive alternatives were attempted prior to the use of side rails for six of 12 final sampled residents (Residents 10, 17, 25, 32, 33, and 239) and five nonsampled residents (Residents 8, 12, 19, 27, and 28) reviewed for side rails use. This failure had the potential to put the residents at risk for entrapment and serious injury. Findings: The FDA issued a Safety Alert entitled Entrapment Hazards with Hospital Bed Side Rails. Residents most at risk for entrapment are those who are frail or elderly or those who have conditions such as agitation, delirium, confusion, pain, uncontrolled body movement, hypoxia, fecal impaction, acute urinary retention, etc., that may cause them to move about the bed or try to exit from the bed. Entrapment may occur when a resident is caught between the mattress and bed rail or in the bed rail itself. Inappropriate positioning or other care related activities…

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

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the ice machine utilized for the residents and staff was maintained in a sanitary condition. * The facility failed to ensure the microwave utilized to warm up the food was in sanitary condition and free of food residue. * The facility failed to ensure the sanitary condition of the hood over the stove was maintained. * The facility failed to ensure the kitchen utensils had a smooth cleanable surface and in good condition. * The facility failed to ensure the kitchenware and kitchen utensils were clean and free of food particle or residue. * The facility failed to ensure the cutting board was kept in a sanitary condition and with cleanable surface. * The facility failed to ensure the countertop mounted can opener was in sanitary condition and free of residue. * The facility failed to ensure the sanitizer test strips had not expired. * The facility failed to ensure the expired…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the residents' entrapment assessments were complete and the measurements were recorded during the bed inspection when identifying areas of possible entrapment with the use of side rails for six of 12 final sampled residents (Residents 10, 17, 25, 32, 33, and 239) and five nonsampled residents (Residents 8, 12, 19, 27, and 28) reviewed for side rails use. These failures had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death. Findings: According to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, the term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in deaths and serious injuries. These entrapment events have occurred in openings within the bed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the proper GT care was provided for three of eight final sampled residents (Residents 17, 24, and 32) and one nonsampled resident (Resident 15) reviewed for enteral tubing. * The facility failed to ensure Residents 15 and 24 had the proper labeling of name and date of the GT feeding bottle, water irrigation bag and irrigation set. * The facility failed to ensure Residents 17 and 32's GT dressings were changed daily as ordered. These failures posed the risk for developing complications related to the residents' GT. Findings: Review of the facility's P&P titled Administration of Enteral Nutrition revised 6/2023 showed gather and prepare the necessary equipment. Label formula bag with two identifiers, feeding rate and hang date and time. Visually inspect the enteral formula for damage to the container, altered formula if the intgrity is compromised or expired. Label flush bag with date and contents i.e.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the intravenous accesses for one nonsampled resident (Resident 30). * The facility failed to ensure the PICC line external catheter and arm circumference measurements were completed and documented in the medical record for Resident 30. In addition, the facility failed to develop a plan of care for the use of PICC line. These failures had the potential to delay the identification of catheter related complications for the resident. Findings: Review of the facility's P&P titled Central Line Placement, Maintenance and Dressing Change dated 6/2023 showed to measure the length of the external PICC line access device and arm circumference with each dressing change and compare with the length documented at insertion. Discrepancies in the measurements from one assessment from to next requires notification to physician. Medical record review for Resident 30 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, medical record review, and facility P&P review, the facility failed to ensure four of 12 final sampled residents (Residents 13, 23, 25, and 33) and seven nonsampled residents (Resident 2, 8, 12, 19, 26, 30, and 27) reviewed for respiratory care were provided with the appropriate respiratory care when: * The facility failed to ensure the nasal cannula was dated and properly stored for Residents 12 and 33. There was no signage for oxygen usage for Resident 33's room. * The facility failed to ensure the nebulizer mask, tubing, and bag were labeled with the date when it was changed and properly stored for Resident 23. * The facility failed to ensure Residents 2, 13, 25, 26,and 30's nasal cannula tubings were labeled, dated, and not touching the floor. In addition, there should date and label the set-up bags for nasal cannula tubings and nebulizer mask. * The facility failed to ensure the manufacture's maintenance care was followed for the BiPap for Resident 26. * The facility failed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, facility document review, and facility P&P review, the facility failed to ensure the medications were properly stored and labeled. * The facility failed to ensure accuracy and complete records of the Medication Room and Medication Refrigerator temperature log. * The facility failed to dispose of an empty bottle of Hy[DATE] (Sodium Hypochlorite Solution) in the Treatment Cart. * The facility failed to ensure Medication Cart 1 was maintained in a sanitary condition. * The facility failed to ensure the medications were labeled with an opened date in accordance with the facility's policy for Resident 22. These failures had the potential to negatively impact the residents' well-being. Findings: Review of the facility's P&P titled Medication Storage and Delivery revised 3/5/24, showed to ensure that all medications are stored under proper conditions of sanitation, temperature, light, moisture, ventilation, segregation, safety and security. 1. On 11/20/24 at 1042 hours, a concurrent…

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

Based on observation, interview, and facility document review, the facility failed to ensure the pureed recipes were followed for two residents who received pureed food from the kitchen. * The facility failed to ensure the puree recipe for steamed green beans was followed. This failure had the potential for not providing nutritional meals to meet the needs of residents who were on a pureed diet. Findings: Review of the facility's document titled Patient Diet List dated 11/20/24, showed two residents received pureed food prepared from the kitchen, with no restrictions to steamed green beans. Review of the facility's diet spreadsheet titled Menu Plan Fall Winter 2024 showed the lunch menu included steamed green beans for PU4 pureed diet. Review of the facility's pureed recipe titled Steamed [NAME] Beans PU4, Version 12, undated, showed to remove the number of portions required from the regular recipe. Blend until smooth adding on three tablespoon of food thickener per 10 servings to achieve a smooth textured product. Final product should be smooth, pudding like, but not runny. One…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to protect the resident's rights to be free from the verbal abuse by CNA 1 for one of two sampled residents (Resident 1) when CNA 1 yelled at Resident 1. Additionally, the facility staff failed to report the incident and intervene in the timely manner as per the facility's P&P. These failures had the potential to cause psychosocial harm to the residents. Findings: Review of the Facility's P&P titled Abuse, Neglect, Misappropriation and Exploitation dated 10/2022 showed the staff report any alleged violations involving verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, and neglect of the resident as well as mistreatment, injuries of unknown source, and misappropriation immediately to the Senior Clinician, or Operational Leader, or District, or National Level and to other officials. Each resident is treated with dignity and respect and focuses on assisting the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure the resident maintained their highest physical well-being for one of two sampled residents (Resident 2). * Resident 2 had a new skin discoloration on her wrist. The facility failed to create a change in condition, notify the physician, develop a care plan, and monitor Resident 2's skin discoloration on her right wrist area. This failure had the potential for the resident to not receive the appropriate care and services needed. Findings: Review of the facility's P&P titled Condition Change of a Patient release dated 10/2022 showed upon recognition of a potentially life threatening or significant change in status, the nurse should communicate with other health care providers to meet the needs of the patient. Under the Definitions, Change of Condition sections, the P&P showed to communicate the changes from the patient's normal status at the time of admission, at…

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

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the ice machine utilized for the residents and staff was maintained in a sanitary condition. * The facility failed to ensure the microwave utilize to warm up the residents' food was in sanitary condition and free of food residue. * The facility failed to ensure the cutting boards were kept in a sanitary condition and with cleanable surface. * The facility failed to ensure the kitchen equipment was air dried prior to storage. * The facility failed to ensure the kitchen utensils had a smooth cleanable surface and were in good conditions. * The facility failed to ensure the kitchen utensils were clean and free of food particle or residue. * The facility failed to ensure the sanitary condition of the hood over the stove was maintained. These failures had the potential to cause foodborne illnesses for the residents in the facility. Findings: Review of the facility's census and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility's P&P review, the facility failed to ensure three of 14 final sampled residents (Residents 3, 14, and 33) remained free from accident hazards. * The facility failed to continue to monitor and document assessment every shift for 72 hours post fall incident for Resident 33. * The facility failed to provide bilateral floor mats to Resident 3 as ordered by the physician and according to Resident 3's care plan interventions. * Resident 14's had bilateral upper and lower side rails in place with a physician's order for only the bilateral upper side rails. These failures had the potential to place the residents at risk for serious injuries. Findings: 1. Medical record review for Resident 33 was initiated on 11/30/23. Resident 33 was admitted to the facility on [DATE]. Review of Resident 33's History and Physical examination dated 10/27/23, showed Resident 33 was alert and oriented to time, place, and person. Review of Resident 33's MDS dated 11/323,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for GT management for two of 14 final sampled residents (Residents 3 and 32) and two nonsampled residents (Residents 13 and 586). * The facility failed to ensure Residents 3, 13, and 586's GT placement was verified as per the facility's P&P prior to administering the medications via GT. * The facility failed to ensure Resident 586's GT medication was administered by gravity. * The facility failed to ensure Resident 32's GT dressing was labeled with date, time, and initial of the nurse as per the facility's P&P. These failures posed the risk for the residents to experience complications related to their GT. Findings: 1. Review of the facility's P&P titled Administration of Enteral Nutrition dated 8/16/23, showed to verify tube placement by assessing for a change in the external length or incremental marking on the tube at the exit site; and visually inspect gastrostomy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 7.41%. Two of three licensed nurses (LVNs 2 and 3) who were observed during the medication administration were found to have made errors. * LVN 3 administered the potassium chloride (electrolyte/potassium supplement) liquid without dissolving the medication with water or juice as per the pharmacy instruction label. * LVN 2 administered the tamsulosin (used to treat enlarged prostate) oral capsule by opening the capsule and mixing the granules with water. However, the pharmacy note on the bubble pack showed to swallow the medication whole. These failures had the potential to negatively affect the residents' health conditions. Findings: 1.a. On 11/29/23 at 0830 hours, a medication administration observation for Resident 13 was conducted with LVN 3. While LVN 3 was preparing Resident 13's morning medications, Resident 13's potassium chloride…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, facility document review, and facility P&P review, the facility failed to store the drugs and biologicals in a safe manner. * The facility failed to dispose the expired and discontinued medications and supplies in Medication room [ROOM NUMBER] and Medication Cart 1. This failure had the potential for the medications to be accidentally administered and/or diverted. * The facility failed to ensure the blood glucose strips containers in Medication Carts 2 and 3 were labeled with the opened date and discard date. This failure had the potential to result in adverse consequences for the residents. * The facility failed to ensure the medications were not left unattended by LVN 2. This failure had the potential for the medications to be diverted. Findings: Review of the facility's P&P titled Disposal/Destruction of Expired or Discontinued Medication dated [DATE], showed the facility should place all discontinued or outdated medications in a designated, secure location which is solely 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 observations, interviews, facility document review, and facility P&P review, the facility failed to ensure two of two IP Nurses completed 10 hours of continuing education annually as recommended by CDPH. This failure had the potential for the IP nurses to not have current and updated infection control training and the potential to provide inaccurate information to the staff. Findings: Review of AFL 20-84 dated November 2020 showed the IP should complete 10 hours of continuing education in the field of IPC on an annual basis. Facilities should provide encouragement and support for IP staff to stay abreast of current news and training sources through a nationally recognized infection prevention and control association. Review of the facility's document titled Job Description for Infection Control (IP) Preventionist revised on November 2022 showed the Knowledge, Skills, Abilities, Expectations of the IP is to remain current with infection prevention and control issues. Review of the facility's document of IP Nurse 1's Certification of Training in Infection Prevention and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, facility document review, and facility P&P review, the facility failed to implement the infection control practices designed to provide the safe and sanitary environment and help prevent the development and transmission of diseases and infections for two of sampled residents (Residents 1 and 2). * The facility failed to ensure the staff practiced the contact isolation precautions when entering the room of one sampled resident (Resident 1) who was on contact isolation precautions * The facility failed to ensure the staff practiced the enhanced barrier precautions during high contact-care for one sampled resident (Resident 2) who was on enhanced barrier precautions. These failures posed the risk for the transmission of diseases-causing microorganisms. Findings: 1. Review of the facility's P&P titled Transmission-Based Precautions released on 6/2022 showed contact precaution is a method designed to reduce the risk of transmission of microorganisms by direct or indirect contact.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development and worsening of pressure ulcers for one of the five sampled residents (Resident 3). * Resident 3's right heel pressure injury was not reassessed for improvement or deterioration. There were no treatment order and care plan developed to address the resident's right heel pressure injury. This failure had the potential for Resident 3 to not receive the appropriate wound treatment. Findings: Review of the facility's P&P titled Wound Identification/Assessment released on 10/2022 showed to document in the patient's EMR (electronic medical record): - Measurements of the size of the wound; - Evaluation of the wound bed; - Evaluation of the surrounding skin; - Evaluation of the drainage; - Evaluation of patient for pain or tenderness to touch; - If a change in condition, notification to healthcare provider; - Evaluation of the process of the wound…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to establish and maintain the infection control practice designed to provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of diseases and infections. * The facility failed to ensure the nursing staff washed their hands and changed gloves after removing the soiled diaper and providing perineal care. In addition, the staff failed to bag the soiled diapers but placed them on the bed while performing the clean tasks for two sampled residents (Residents 3 and 4). This failure posed the risk for spreading the infectious organisms throughout the facility. Findings: Review of the facility's P&P titled Routine Bathing dated 10/22 showed the following procedure for incontinence clean-up: 1. [NAME] gloves and open pre-packaged bathing cloths, remove 1- 2 cloths, remove bulk of stool using under pad or dry disposable patient washcloths. 2. Remove soiled gloves. 3. [NAME]…

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