Oakwood Healthcare Center

Based on interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1) was treated with dignity and respect when Resident 1 was rushed by Certified Nursing Assistant (CNA) F and spoken to with a demeaning tone and attitude.This failure resulted in Resident 1 feeling angry, helpless and emotionally stressed and had the potential to result in embarrassment and neglect which could result in negative clinical outcomes.Findings: The facility's policy revised 8/2025, titled, Residents' Rights, was reviewed and indicated employees are to treat all residents with kindness, respect, and dignity and honor the exercise of residents' rights. The facility's policy revised 3/2017, titled, Quality of Life-Dignity, was reviewed and indicated that each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. All residents shall be treated with dignity and respect at all times. Demeaning practices and standards of care that compromise dignity is prohibited. The staff shall promote dignity 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 ensure one of four sampled residents (Resident 3) was free from physical and verbal abuse when Resident 2 yelled profanity and was swinging at Resident 3 in the hallway. This failure had the potential to result in emotional stress, embarrassment, feelings of neglect, anger, and the potential for negative clinical outcomes.Findings: The facility's policy revised 5/30/24, titled Abuse and Prevention Management, was reviewed and indicated the purpose of this policy is to address the health, safety, welfare, dignity, and respect of residents by preventing abuse, neglect, misappropriation of resident property, exploitation, and mistreatment, including freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat medical symptoms. This facility's policy also indicated the facility does not condone any form of resident abuse, neglect, misappropriation of resident property, exploitation, and/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 observations, interviews, and record reviews, the facility failed to ensure the environment was free from hazards when they did not follow their laundry policies and procedures (P&P) and did not provide Laundry Tech (LT) A with required competencies (training and education). This had the potential to contribute to smoldering (burn slowly with smoke but no flames) laundry that was discovered in a laundry bag.Findings: A review of the facility's P&P titled, Laundry-Sorting, Washing and Drying, revised 1/1/12, indicated, dryers would be unloaded after the drying cycle was complete. The P&P indicated, to remove grease and stains, when needed, kitchen and housekeeping laundry would be pre-soaked in degreaser (a chemical that broke down grease and oil) or detergent, prior to washing. A review of the undated Laundry Tech, job description, indicated the LT would maintain a safe working environment. A review of the Full NFIRS v1.0 (fire department report), dated 12/1/25, indicated, the fire department arrived at the facility on 12/1/25 at 2:54 am due to facility staff smelling smoke…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 that staff consistently implemented the physical mobility care plan for one of three sampled residents (Resident 1) when Resident 1's care plan indicated that she would be transferred using a Hoyer lift (a mechanical lifting device), and staff were not consistently using the Hoyer lift and transferring her with two people lifting her up by her arms. This had the potential for Resident 1 to sustain injuries from staff not using the Hoyer lift and negatively impact her ability to attain or maintain her highest practicable level of emotional and physical well-being. Findings:A review of the facility's policy and procedure titled, Comprehensive Person-Centered Care Planning, dated 9/7/23, indicated a care plan would be developed for each resident that included standards for meeting safety and health care needs.During a review of Resident 1's medical record indicated that Resident 1 was admitted to the facility on [DATE] with a diagnoses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop a care plan (a written plan that outlined how the facility and staff would meet the resident needs) for four out of five sampled residents (Residents 2, 3, 4, and 5) when there was no care plan present that described the use of a mechanical lift (medical device on wheels that was used to transfer residents who could not bear their own weight).This had the potential for residents not to obtain or maintain their highest practical physical, mental, and psychosocial well-being and lead to potential accidents from not being transferred properly.Findings:A review of the facility's policy and procedure titled, Comprehensive Person-Centered Care Planning, dated 9/7/23, indicated a care plan would be developed for each resident that included standards for meeting safety and health care needs.A review of Resident 2's admission Record, dated 7/18/24, indicated, Resident 2 was admitted to the facility on [DATE] with the diagnosis of quadriplegia (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 observation, interview, and record review, the facility failed to follow their Resident Safety and Maintenance Service policies and procedures (P&P) when:1. Facility staff knew the mechanical lift (device on wheels used to transfer residents that could not walk) was broken, did not report it, and used it to transfer four out of five sampled residents (Residents 2, 3, 4, and 5); and2. The Maintenance Department failed to ensure the broken mechanical lift was removed from use, reported as broken, and did not consistently perform monthly routine maintenance of all mechanical lifts that were utilized in the facility.This had the potential to cause an accident and injuries from using broken equipment to lift and transfer all residents who required the use of a mechanical lift and negatively impact their physical and emotional well-being.Findings: 1. A review of the facility's P&P titled, Resident Safety, revised 4/15/21, indicated, any facility staff that identified an unsafe situation, should immediately…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to treat two of three residents (Resident 15 and Resident 17) with respect and dignity when:1. The facility failed to ensure that Resident 17 was provided with appropriate clothing.This failure resulted in Resident 17 experiencing social isolation when unable to participate in facility activities and feeling embarrassed and undignified when required to attend outside appointments wearing only a hospital gown.2. Certified Nursing Assistant (CNA ) J did not provide Resident 15 with privacy and dignity when the privacy curtain was not pulled closed when Resident 15 was receiving personal care in their room. This failure resulted in Resident 15 being left vulnerable when staff failed to provide privacy during personal care, potentially causing emotional distress and diminishing Resident 15's sense of dignity and autonomy. Findings: 1. During a review of the facility’s policy titled, Residents Rights – Quality of Life, revised 1/2012, 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 resident council grievances were acted upon and promptly addressed for 12 confidentially interviewed residents when the residents stated there was an ongoing delay in answering call lights and getting care on the night shift. Refer to F726.This failure resulted in residents experiencing frustration with long wait times for needed care and had the potential to put residents at risk for unmet needs.Findings:A review of a facility policy titled, Resident Council revised 11/1/2013, indicated the purpose of the Resident Council was to promote the exercise of resident rights by providing a forum for residents to voice concerns, share input on facility operations, and for the facility to ensure issues raised are reviewed and addressed through the quality assessment and assurance committee.During a review of the facility's record titled, Resident Council Minutes, indicated:a. On 5/13/25, resident council minutes indicated that call light waiting times were still a concern at all times of the day. The response from 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 two out of five direct care nursing staff had necessary competencies and skills sets to meet the care and services when: 1. CNA J and F had not worn an N-95 mask (recommended when caring for residents with Covid) when providing care to Resident 28, who had Covid. Refer to F880. 2. CNA J did not ensure privacy for Resident 15 during care. Refer to F550. These failures resulted in resident care needs not to be met, residents' right to privacy violated, and had the potential to spread infection in the facility. Findings: 1. During a concurrent observation and interview on 8/19/25 at 10:52 am, with CNA F, CNA F entered Resident 28's room (who had Covid) with a surgical mask (not as effective against Covid as the N-95 mask), CNA F confirmed she wore a surgical mask. CNA F stated she did not like to wear N-95 masks because, they are too tight. CNA F stated she was aware that the facility's policy was for staff to wear N-95 masks when in Resident 28's room. CNA F stated the Infection Preventionist (IP) had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 their infection control prevention program was implemented to prevent the spread of Covid (a serious virus that causes fever, tiredness, cough, breathing difficulties, loss of smell and taste) when Certified Nursing Assistants (CNAs) were observed wearing surgical masks to care for one resident with Covid (not as effective as an N-95 in preventing the spread of the Covid virus), as their policy directed. (Resident 28) This had the potential to spread the Covid virus to other residents, visitors and staff. During a record review of facility's policy titled, Infection Control - Policies and Procedures date 1/1/12, indicated, The administrator, through the Infection Control Committees, adopts the infection control policies and practices to reflect the facility's needs and operational requirements for preventing transmission of infections and communicable disease as set forth in current CDC guidelines and recommendations.During a record…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents sampled for discharge (Resident 61) had the required transfer and discharge documentation in their chart when Resident 61 was transferred to a General Acute Care Hospital (GACH) and: Resident 61 was not provided with a Notice of Transfer or Discharge. Resident 61 was not provided with a notice of a bed hold (holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization).The Ombudsman's office (a government appointed person who actively supports the rights of residents) was not provided with Resident 61's Notice of Transfer or Discharge form. These failures had the potential in Resident 61 not being fully informed of his right to request a bed hold and to return to the facility after hospitalization, and the potential for Resident 61 not having the opportunity to have had an advocate to inform him of his right to appeal a facility-initiated discharge.FindingsA…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 proper managing of a gastrostomy tube (G-tube, a tube inserted into the stomach through the abdominal wall to deliver liquid nutrition, fluids, and medication) for one of two residents sampled for G-tube management (Resident 45), when the Treatment Nurse (TN) placed Resident 45 in a flat position while the enteral feeding (liquid nutrition and fluids provided through a tube inserted into the stomach) pump was still on.This failure had the potential for the liquid nutrition to back up into Resident 45's esophagus (a tube from the throat to the stomach) and cause aspiration (where liquid nutrition enters the lungs) and can lead to a deadly lung infection called aspiration pneumonia. Findings:The facility policy titled Enteral Feedings was reviewed and the policy indicated The head of bed should be elevated 30 degrees during enteral feedings.A review of Resident 45's admission record indicated Resident 45 was admitted on [DATE] with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to properly store, dispose, and document for the medication that had been discontinued in one of two observed medication rooms (Medication room [ROOM NUMBER]). This had the potential for discontinued medications to be available for resident use and/or diversion (taking without permission), by staff which could negatively impact the residents' health status. A review of facility policy titled, Medication Destruction for Non-Controlled Medications dated 2006, indicated unused, unwanted and non-returnable medications should be removed from their storage area and secured until destroyed. Medication destruction occurs only in the presence of at least two licensed healthcare professionals or according to regulation and applicable law. Licensed healthcare professionals witnessing the destruction ensure that the following information is entered on the medication disposition form.dates, signatures of witnesses.A record review of facility'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 observation, interview, and facility policy and procedure review, the facility failed to ensure visitors and staff who handled food brought from the outside were educated on safe food handling practices. This failure had the potential for unsafe food handling which could lead to foodborne illness in the 53 residents receiving an oral diet who resided in the facility. Findings:During a record review of facility policy titled DD14 Food Brought in by Visitors Revised 4/24/25, indicated food may be brought to a resident by visitors and the facility staff will be made aware of this policy addressing outside food being brought to residents and how to apply it, assist the family/visitors to understand safe food handling practices (such as safe cooling/reheating processes, hot/cold holding temperatures, preventing cross contamination, hand hygiene, etc.), use safe food handling practices when assisting family or visitors with reheating or other preparation activities, and provide resident/resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their Fall Management Program policy and procedure (P&P) for one out of three residents sampled for falls (Resident 1). Specifically, the facility staff initiated the required post-fall documentation on 5/19/25, two days after Resident 1 fell, instead of initiating a Post-Fall Huddle (includes updating the care plan, interviewing witnesses and documentation in the medical record), within 15-20 minutes after Resident 1's fall on 5/17/25. This failure caused a delay in the facility-initiated fall investigation to be completed, had the potential to cause a delay in care, and placed Resident 1 at an increased risk for more falls. Findings: A review of the facility's P&P titled, Fall Management Program, revised 3/13/21, indicated, after a resident had a fall, the Licensed Nurse (LN) would perform a post-fall evaluation (assessments and documentation that were required to be completed) after a resident fell. The P&P indicated, the Physician, Director…

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

Based on interview and record review, the facility failed to comply with state and local public health authority requirements for reporting an outbreak when a total of 11 residents and 3 staff had been reported with signs and symptoms of respiratory illness, such as cough, running nose, sore throat, shortness of breath (SOB– a sensation of running out of the air) from 3/30/25 to 4/8/25. The facility did not report the occurrence to California Department of Public Health (CDPH) until 4/8/25. This failure had the potential to result in a widespread infection in the facility that could compromise the health of the residents, visitors, and staff. Findings: During a review of the facility's policy titled, Infection Control Surveillance (the ongoing process of monitoring infections and infection prevention and control processes within a healthcare facility) , revised 3/1/14, indicated: - The purpose of the policy is to, Provide surveillance of Healthcare-associated Infections (HAIs – infections that patients get while they are receiving healthcare or soon after receiving healthcare) 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 protect one of four sampled residents (Resident 2) from verbal abuse when Resident 1 made derogatory comments and yelled profanities directed at Resident 2 while in the hallway. This failure had the potential to negatively affect the psychosocial and mental health for Resident 2 and other residents within hearing range. Findings: A review of the facilities policy titled, Abuse Prevention and Management revised 5/30/24, indicated, Verbal abuse is defined as any use of oral, written, gestured communication, or sounds that willfully include disparaging (to belittle the value or importance of someone) and derogatory (showing a disrespectful attitude) terms directed to residents within their hearing distance. A review of the facilities document titled, Resident [NAME] of Rights dated 5/11, the policy indicated patients shall have the right to be free from mental and physical abuse. A review of Resident 1's admission record showed he was initially admitted…

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

Based on interview and record review, the facility failed to report an abuse allegation for one of four sampled residents (Resident 2), to the California Department of Public Health (CDPH), Ombudsman (Resident advocate organization), and local law enforcement, within two-hours after Resident 1 made derogatory comments and yelled profanities directed at Resident 2 while in the hallway. This had the potential for Resident 2, and other residents, to be vulnerable and unprotected from mistreatment, and negatively impact their emotional and psychosocial well-being. Findings: On 4/22/25 at 9:00 am, an onsite visit was made to the facility to investigate a self-reported abuse allegation which had occurred on 3/23/25. The self-reported abuse document titled, Intake Information dated 3/26/24, indicated Nursing Supervisor (NS) reported the abuse allegation to CDPH, Ombudsman, and local law enforcement on 3/26/25, three days after the event, that Resident 1 was being verbally aggressive to Resident 2, because she wasn't able to move out of his way quick enough. Resident 1 became angrier 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 ensure one of four sampled residents (Resident 1) had a care plan developed to address Resident 1's use of Methamphetamine (illegal drug in the form of [NAME] Meth and is highly addictive and causes feelings of euphoria and increased alertness and energy and can cause violence, paranoia, anxiety, rapid heart rate, irregular heartbeat, stroke, or even death). This deficient practice had the potential to result in a decline in Resident 1's health status related to the lack of interventions and monitoring for signs and symptoms of substance abuse which could result in a potential overdose. Findings: A review of the facility's policy titled, Comprehensive Person-Centered Care Planning revised November 2018, indicated, It is the policy of this Facility to provide person-centered, comprehensive and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral and environmental needs of residents in order 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 that one of four sampled residents (Resident 1) who had a known Substance Abuse Disorder (SUD, an individual who uses and/or abuses illegal drugs and/or alcohol), was provided with the necessary monitoring and supervision to prevent avoidable accidents and hazards when: 1. Resident 1 frequently went out of the facility on pass and was not evaluated or assessed for signs of drug use and/or overdose upon his return to the facility. 2. Nursing staff had not received training or education on how to manage potential emergencies that could arise for residents with a SUD. (Refer to F741) 3. The facility failed to develop a SUD plan of care for Resident 1 with goals and interventions to mitigate potential accidents, hazards, and drug overdose. (Refer to F656) These failures had the potential for changes in Resident 1's condition to go unrecognized and nursing staff that were not prepared to address emergencies related to Resident 1's SUD, which could…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 that staff were trained and competent to care for one of one sampled resident (Resident 1) who had a Substance Use Disorder (SUD, an individual who uses and/or abuses illegal drugs and alcohol) when Resident 1 had many numerous physical and verbal altercations with other residents and staff over the past year, and staff indicated they did not know how to deal with these behaviors of someone with a SUD and indicated they had not received training on it. This failure has the potential for Resident 1 not to receive care and services to safely manage his SUD and result in a decline in his physical, emotional and psychosocial well-being and put other residents' health, safety and welfare at risk. Findings: A review of the, Facility Assessment (an assessment to determine what resources are necessary to care for its residents competently during both day-to day operations [including nights and weekends] and emergencies) dated 12/6/24,…

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 2a. During a review of Resident 20's admission record, indicated that she was originally admitted to the facility on [DATE], and was readmitted on [DATE] with diagnoses which included cerebral infarction (a medical condition where blood flow to the brain is interrupted, leading to damage or death of brain tissue), dysphagia (difficulty swallowing) following cerebral infarction, aphasia (a disorder that makes it difficult to speak) following cerebral infarction, and gastrostomy status (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). Resident 20 was not her own health care decision maker. During a review of Resident 20's MDS, dated [DATE], the MDS indicated that a Brief Interview for Mental Status (BIMS) shouldn't be conducted, because Resident 20 was rarely/never understood. During a concurrent observation and interview on 2/19/25 at 7:41 am, with LN B, in Resident 20's room, an unlabeled bag full of clear liquid 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 provide showers twice a week and nail care as indicated on the residents Activities of Daily Living (ADL's refers to dressing, bathing, grooming, toileting and hygiene) record, for 3 of 18 residents who were sampled for ADL care. (Residents 5, 7, and 41) when: 1. Resident 5 missed two of his Saturday showers which were important to him, because he e attended Spiritual Meetings on Sundays. This had the potential to negatively impact Resident 5's emotional well-being. 2. Resident 7 had unwanted body odor. This had the potential for Resident 7 to experience embarassment and skin irritation. 3. Resident 41 had long fingernails with jagged sharp edges and thick dark brown substances under each nail. This had the potential to cause infection and skin tears from long sharp nails. Findings: During a review of the facility's policy revised 1/1/2012, titled, Showering and Bathing, indicated a tub or shower bath is given to the resident to provide…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safe use and accountability of narcotic controlled medications (prescription narcotic drugs of abuse), when: Resident 61's Norco (Hydrocodone-APAP; an opioid/narcotic pain medication) was removed from Controlled Drug Record (CDR, an accountability sheet that tracked narcotic removal with nurses initial, date, and time), without the corresponding administration documentation in Resident 61's MAR (Medication Administration Record- a legal document that listed the drugs given to Resident 61). This failure could contribute to unsafe drug handling, poor pain control, and risk of drug diversion (drug loss). Findings: During a record review of Resident 61's MAR, dated 2/2025, the record indicated a doctor's order for PRN (as needed) use of pain medication called Norco as follows: Hydrocodone-Acetaminophen oral tablet 5-325 MG ( . Same as Norco a combination of opioid drug pain reliver; MG stands for Milligram, a unit of measure); Give 1 tablet by mouth every 6 hours as needed for Moderate to Severe pain . Start Date…

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

Based on interview, observation, and record review the facility failed to ensure safe use of psychotropic medications (medication that alters mood, behavior and cognition (thinking, learning and understanding)), on one out of five residents (Resident 42) reviewed for unnecessary drug use with census of 75 when: Resident 42's PRN (as needed) use of phenobarbital (an anti-seizure medication also used to treat mood and behavior problems), was not evaluated and assessed by the facility and medical doctor for duration of use based on facility's policy. These failures could contribute to unsafe use of psychotropic medications that could have placed resident at risk for adverse consequences. Findings: Review of Resident 42's electronic medical record titled, admission Record indicated Resident 42 was admitted to the facility with diagnosis of heart disease including heart rhythm disease, depression, recurrent falls, and on 12/24/24 was started on palliative care (specialized medical care that helps people with serious illnesses manage symptoms and improve quality of life). Review of…

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

Based on observation, interview, and record review the facility failed to ensure safe medication administration practices when medication error rate was more than 5% (% or percentage- number or ratio that expressed as a fraction of 100) with resident census of 75. Medication administration observations were conducted over multiple days, at varied times, in random locations throughout the facility. The facility had a total of three errors out of 31 opportunities which resulted in a facility wide medication error rate of 9.68% in 2 out of 9 residents (Resident 19 and Resident 71) observed for medication administration as follow: 1. The facility failed to ensure Resident 19 received food with the potassium (an essential electrolyte needed by all tissues in the body) administration. 2. The facility failed to ensure Gastric-tube (G-tube, a small tube that's surgically inserted into the stomach through the abdomen for feeding, hydration, and medicine to be delivered directly to the stomach) medications were administered one at a time for Resident 71. These failures may result in unsafe…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, observation, and record review, the facility failed to ensure safe medication storage practices in the medication room (a locked room used to store medications and supplies) and two out of 5 medication or treatment carts (a mobile cart stored medication and supplies for immediate use) based on manufacturer specifications with census of 75 when: 1. Medication Cart 3 at Station 2 stored an unopened and unused eye drop called latanoprost (or Xalatan- used to treat eye disease) that required refrigeration based on manufacturer specification. An undated glucometer (a device that measure blood sugar) test strips bottle (testing supply inserted in the glucometer to measure blood sugar) based on manufacturer specification. 2. Medication room at Station 1 stored expired test tube (blood test tube is a sterile, vacuum-sealed tube used to collect and store blood samples for medical testing) and throat culture swab kit (a kit used to swab the throat and check for infection) in the active storage areas.…

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

Based on observation, interview, and record review, the facility failed to maintain professional standards of practice to ensure food service safety for the residents of the facility when during the initial tour food preparation equipment was not clean. These failures had the potential for risk of contaminating food with germs and causing a food born illness. Findings: A review of the Food and Drug Administration (FDA- federal agency that protects and promotes public health by regulating various products, such as drugs, devices, food, cosmetics, and tobacco) Food Code, 2022, section 4-601.11, indicated, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, indicated, (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. During a concurrent observation and interview with the Dietary Manger (DM) in the kitchen on 02/17/25 at 8:43 am, observed were four…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain medical records that were complete for one out of 18 sampled residents (Resident 46) when Restorative Nursing Assistant (RNA, trained in providing residents with range of motion exercises [ROM, exercises that assist with movement of the arms or leg]) did not document care that was provided. This failure caused medical records to be incomplete which caused an inability to know of physician care ordered was provided or not. Findings: A review of the facility's policy and procedure titled, Completion and Correction, revised 1/1/12, indicated, treatments provided to residents would be documented in the resident's medical record as they occurred and that medical records would be complete. A review of Resident 46's admission record, dated 10/12/20, indicated, admission to the facility on [DATE] with the diagnoses of dementia (memory loss) and trigger finger (a condition where the finger gets stuck in a bent position then snaps straight), left middle…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 did not follow their Arbitration Agreement (a binding contract that explained how a resident would resolve disputes against the facility) policy and procedure (P&P) for three of three residents (Residents 27, 42, and 48) that were sampled for arbitration when: 1. Resident 27 did not fully understand the terms and conditions of the arbitration agreement, stated it was not explained in a manner that was understood, and felt rushed during the process; and 2. Resident 42's responsible party (RP, decision maker/representative) stated, facility staff did not discuss the arbitration process or agreement with RP and was not aware RP had signed a binding arbitration agreement; and 3. The facility's Interdisciplinary Team, (IDT, a group of facility staff that discuss, monitor, and coordinate care that a resident received) acted as Resident 48's surrogate (representative/RP) and entered Resident 48 into a binding arbitration agreement with the facility. These…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an electrical outlet cover in room [ROOM NUMBER], located near a privacy curtain (a fabric curtain that hung from the ceiling and provided privacy to the residents), was maintained when the electrical outlet cover was loose and there was an exposed gap between the electrical outlet cover and the wall. The failure to maintain an electrical outlet and it's cover could be considered a safety hazard. Findings: A review of the facility's policy and procedure (P&P) titled, Maintenance Service, revised 1/1/12, indicated, the maintenance department was responsible for maintaining all areas of the facility and the purpose of the (P&P) was To protect the health and safety of residents, visitors, and Facility Staff. During an observation on 2/17/25 at 9:46 am, located in room [ROOM NUMBER], an electrical outlet cover was observed to have a gap between it and the wall and was loose. The electrical outlet cover was located near a privacy…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 report a physical abuse allegation for one of two residents (Resident 1) to the California Department of Public Health (CDPH) within two-hours after Resident 1 alleged a tall, thin, male staff member, physically abused her. This had the potential for Resident 1, and other residents, to be vulnerable and unprotected from mistreatment, and negatively impact their emotional and psychosocial well-being. Findings: A review of the facility's policy titled, Abuse Prevention and Management revised 5/30/24, indicated, The administrator or designated representative will notify law enforcement, by telephone immediately, or as soon as practicable possible, but no longer than (2) hours of initial report AND send a written SOC341 (a form used to report suspected dependent adult/elder abuse to certain entities) report to the Ombudsman (a person who investigates and tries to resolve complaints for residents), Law Enforcement, and CDPH Licensing and Certification…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a care plan was developed or revised to determine interventions for one of two sampled residents (Resident 1) when Resident 1 expressed he wanted to die. This failure had the potential for Resident 1 to experience a decline in psychosocial and physical wellbeing. Findings: A review of the facility's policy titled Behavior-Threats to Harm Self revised March 2017, indicated the policy's purpose is To respond appropriately to resident who are verbalizing suicidal thoughts and/or comments about self-harm. Resident threats of suicide or self-harm must be reported immediately to the Director of Nurses, Designee and Social Services during regular business hours. The Social Service staff and/or Licensed Nurse will interview the resident to seek additional information regarding an immediate plan or intent to injure him/herself. The residents Care Plan will reflet interventions aimed at decreasing the resident's thoughts of self-harm…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medications were administered per physician ' s order when one of three residents (Resident 1) received Tacrolimus External cream (a medicated ointment for skin rash with petroleum (a skin protectant used as a moisturizer to treat or prevent dry, rough, scaly, itchy skin) as an ingredient) in error and was allergic to it. This failure caused Resident 1 to experience burning to his back. Findings: During a review of the facility ' s policy titled, Medication Administration revised January 1, 2012, indicated, The purpose is to ensure the accurate administration of medications for residents in the Facility. Medications will be administered directed by a Licensed Nurse and upon the order of a physician or licensed independent practitioner. Orders will be reviewed for allergies, food/drug interaction. A review of Resident 1 ' s admission Record (undated), indicated Resident 1 was admitted on [DATE] with diagnoses that included pneumonia, chronic…

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

Based on interview, and record review, the facility failed to ensure Licensed Nurses (LNs) documented in the electronic medical record for one of six sampled residents (Resident 1) when Resident 1 had a change of condition and was transferred to the acute hospital. These failures resulted in an inaccurate record and had the potential to affect developing an accurate resident plan of care when a change of condition was not documented in the record. Findings: During a review of the facility's policy titled, Change of Condition Notification , revised 4/1/2015, at the section of Documentation , indicated: a. A Licensed Nurse (LN) will document the following: - Date, time, and pertinent details of the incident and the subsequent assessment in the Nursing Notes. - The time the Attending Physician was contacted, the method by which he was contacted, the response time, and whether or not orders were received. - The time the family/responsible person was contacted. - The incident and brief details in the 24-Hour Report. - If the resident is transferred to an acute care hospital, complete 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to protect residents' rights to be free from physical, psychological (mental), or verbal sexual abuse for two of four sampled residents (Residents 1 and 3) when: 1. Resident 2 made sexually explicit comments to Resident 3 and continued to harass her after staff and law enforcement asked him to stop. 2. Laundry Personnel 2 (LP2) touched Resident 1 on the shoulder and whispered into her ear, which made Resident 1 feel very uncomfortable. These failures caused mental suffering and feelings of distress for Resident 3 and an increase in anxiety for Resident 1. Findings: During a review of facility Policy and Procedure (P&P) titled Unusual Occurrence Reporting, dated 8/1/12, the P&P indicated its purpose was to ensure timely reports are made to designated agencies as required by state and federal laws and regulations. The P&P further indicated the facility will report by phone and in writing to the appropriate State or Federal agencies allegations…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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's Administrator (ADM) failed to ensure effective oversight and necessary resources to ensure resident care services were met to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident when: 1. ADM did not ensure the abuse policy was implemented to protect residents' rights to be free from physical, psychological (mental), or verbal sexual abuse, and allegations of abuse were identified/reported. Refer to F600 and F609. 2. ADM did not report an unusual occurrence of a facility lockdown. 3. ADM did not ensure the building equipment was operating and the environment was safe. Refer to F689 and F908. This put all residents at risk for ongoing abuse and accidents and hazards. Findings: During a review of the facility undated document titled, Administrator Job Description, indicated the administrator (ADM) reports to Governing Body & President of Operation. The ADM's principal responsibilities and duties are serves as liaison between Governing Body and Facility Personnel, implementing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintain essential equipment in safe operating condition when: 1. An air conditioning unit leaked for three days from the ceiling in room [ROOM NUMBER]A (Resident 5's bedroom). This failure resulted in Resident 5 stating she felt frustrated and worried and had the potential for avoidable life-threatening hazards such as ceiling collapse from water damage, electrocution, and infection from mold and bacterial growth. 2. Facility staff silenced a malfunctioning fire system alarm for five hours. Failure to maintain the fire system had the potential to place all 89 residents, staff, and visitors at risk of injury or death in the event of a fire. Findings: During a review of facility Policy and Procedure (P&P) titled Maintenance Service: Operational Manual – Physical Environment, dated 1/1/12, the P&P indicated its purpose was to protect the health and safety of residents, visitors, and staff by maintaining all areas of the buildings, grounds,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 allegations of abuse within 24 hours for one of four residents (Resident 1). This failure had the potential for ongoing staff-to-resident abuse for all 89 residents within the facility. Findings: During a review of facility Policy and Procedure (P&P) titled Unusual Occurrence Reporting, dated 8/1/12, the P&P indicated its purpose was to ensure timely reports are made to designated agencies as required by state and federal laws and regulations. The P&P further indicated the facility will report by phone and in writing to the appropriate State or Federal agencies allegations of abuse or neglect and other unusual occurrences that interfere with facility operations and affect the welfare, safety, and health of residents, employees, or visitors. Unusual occurrences are reported to the appropriate agency within 24 hours by telephone and then confirmed in writing. The facility conducts and documents timely and thorough investigations into all unusual occurrences and takes corrective action as appropriate.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident environments remained free from avoidable accidents and hazards when Resident 5 lived in her bedroom for three days with a ceiling leak from a malfunctioning rooftop air conditioning unit. This failure resulted in a negative psychosocial (relating social conditions to mental health) outcome when Resident 5 stated she felt frustrated and worried, and put her a risk for accidents and hazards. Findings: During a review of facility records titled Administrator (ADM) Job Description, undated, the record indicated ADM is responsible for directing and monitoring compliance with federal and state regulations and laws, coordinating compliance with established policies and procedures, hiring and training competent and committed staff, and positioning the facility to operate in a successful manner. During a review of facility Policy and Procedure (P&P) titled Maintenance Service: Operational Manual – Physical Environment, dated…

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

Based on observation, interview, and record review, the facility failed to ensure food safety and sanitation requirements were met in accordance with professional standards for food service safety when: 1. Expired food items were present in refrigerator/freezers and dry storage areas; 2. Food was not properly stored, labeled and dated; 3. Kitchen and food service equipment were not in sanitary condition; 4. The kitchen environment was not in sanitary condition; 5. An eyewash station was present in the handwashing station. These failures created a potential risk for exposure to food- and waterborne illnesses in a medically vulnerable population of 78 residents who received food prepared in the kitchen. Findings: 1. During review of facility Policy & Procedure (P&P) titled Food Storage: Operational Manual - Dietary Services, revised 7/25/19, the P&P indicated food items will be stored, thawed, and prepared in accordance with good sanitary practice, and all items will be correctly labeled and dated. During concurrent initial kitchen tour and interview with Certified Dietary 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, and record review, the facility's Administrator (ADM) failed to ensure effective oversight and necessary resources to ensure resident care services were met to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident when: 1. The ADM failed to ensure the resident environment was safe, clean, and free from accident hazards. This resulted in an immediate jeopardy for failure to provide a system to ensure the safety of the resident and prevent the outsiders from entering the facility. These failures had the potential to put all the residents at risk for accident and hazards. Refer to F 689. 2. The ADM failed to ensure that the facility have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services. Refer to F 725, and F 726. 3. Dietary services did not follow national standards and guidelines for kitchen cleanliness, and the safety of the food storage. These failures had the potential for…

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

Based on interview and record review, the facility's Governing Body (GB), legally responsible for establishing and implementing facility policies, failed to effectively manage the facility when: 1. The GB did not ensure the administrator (ADM) had capital expense approval to ensure of the safety of the residents. Refer to F 689. 2. The GB did not ensure sufficient and competent staffing was present to meet the needs of all residents. Refer to F 725, F 726. 3. The GB did not ensure adequate oversight and monitoring of the dietary department. Refer to F 812. 4. The GB failed to ensure and effective Quality Assessment and Assurance Program to identify, implement corrective actions and evaluate their effectiveness. These failures led to an Immediate Jeopardy (IJ) being declared on 5/22/2024 at 11:25 am, at F 689. On 5/22/2024, at 11:25 am, an Immediate Jeopardy (IJ) was declared, when one of the seven facility doors leading to the outside was damaged and could not be completely closed and remaining partially open and unlocked. The facility failed to ensure the residents' safety and…

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

Based on interview and record review, the facility failed to have an effective Quality Assurance Performance Improvement (QAPI) committee when they did not identify nor correct facility issues to ensure care and services met residents needs when: 1. The facility had two unlockable doors, one -as a fire door with a broken hinge, leading to the facility's backside parking lot that nears a creek and a busy road. The facility's QAPI Program failed to monitor and take action to improve known defects in the facility's process for obtaining the vender's quote for the cost of the fire door and the capital expense approval. This resulted in an immediate jeopardy for failure to provide a system to ensure the safety of the resident and prevent the outsiders from entering the facility. Refer to F 689. 2. Dietary services did not follow national standards and guidelines for kitchen cleanliness, and the safety of the food storage. These failures had the potential for the spread of infection, and foodborne illness to occur in residents. Refer to F 812. 3. Dietary services did not meet 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 sustain a safe and sanitary environment for 82 out of 82 residents when: 1. During an inspection of the water-borne pathogen prevention program, the Maintenance Supervisor (MAINT) was unable to consistently provide proof that water temperatures were being monitored, and, 2. Personal protective equipment (PPE) consisting of a box of surgical masks, eye goggles and a face shield designed to be used during direct patient care were found in rusted employee lockers, and PPE and medical supplies were found to be stored in a basement around an active water leak directly below the dishwasher upstairs, and, 3. Nurses were observed to apply disinfecting agents (solutions designed to kill disease-causing pathogens) for inadequate lengths of time on shared medical equipment. These failures had the potential for contamination (the transfer of harmful pathogens from one source to another) and posed a threat to the physical well-being of residents, staff, and visitors. Findings: 1. A review was made of a facility policy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure resident council grievances were addressed and resolved when confidential interviews indicated ongoing facility issues. This resulted in the residents to express feelings of helplessness and not being wanted. Findings: A review of a facility policy titled, Resident Council revised 11/1/2013, indicated the purpose was to promote the exercise of resident rights at the facility. The residents are to have input in the operation of the facility. The resident council provides feedback on procedures that govern the facility. Make recommendations for the improvement of resident services provided by the facility. If the council raises a concern the department responsible for the issue or service is responsible for addressing the concern. The facility's Quality Assessment Assurance Committee review the resident council minutes as part of it's quality review. The Administrator reviews the minutes and any responses from departments and these are presented at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, medical record review and facility policy and procedure review, the facility failed to ensure two of six resident's responsible parties (Residents 63 and 4) were notified of significant unplanned weight loss. These failures resulted in a delay of communication of Residents 63 and 4's significant weight losses to their responsible parties which had the potential to negatively impact the resident's well-being. Findings: Review of the facility policy and procedure titled, Evaluation of Weight and Nutritional Status revised April 21, 2022, showed, I. Clinical Evaluation B. Any resident that varies from the previous reporting period by 5% in 30 days, 7.5% in 90 days, 10% in 180 days, will be evaluated by the IDT- Nutrition and Weight Variance Committee to determine the cause of weight loss/gain and the intervention(s) required. i. Once weight gain or loss as described above is identified, the IDT -Nutrition and Weight Variance Committee will: C. Notify the responsible party. 1. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the facility environment was maintained safe, comfortable and homelike when: 1. Air temperatures were cold throughout the building. 2. The outside resident patio and facility grounds were not maintained. 3. Multiple screens were missing from residents rooms and dining room. This resulted in residents that were cold and had the potential for insects to enter the facility through windows without screens and violated the residents right to have a homelike environment. Findings: A review of a facility policy titled, Resident Rooms and Environment revised 1/1/2012, indicated the purpose was to provide residents with a safe, clean, comfortable and homelike environment. Ensuring comfortable temperatures and cleanliness and order. 1. During confidential interviews on 05/22/24 9:30 am, residents stated the temperature in room [ROOM NUMBER] was freezing. During an facility environmental tour on 5/23/24 at 9 am, with the Maintenance Assistant…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an ongoing activity program to meet the needs and interests for two of two sampled residents (Residents 47 and 61) to ensure the residents maintained their highest physical, mental, and psychosocial well-being. This deficient practice had the potential not to meet the highest practicable psychosocial well-being of the residents. Findings: A review of Resident 47's admission Record shows Resident 47 was first admitted to facility on 2/14/22, with medical diagnoses including Displace bimalleolar fracture of left lower leg (a broken left lower leg), Chronic lymphocytic leukemia of B-cell type (a cancer of the blood), and Major depressive disorder, recurrent (Depression). A review of Resident 47's Minimum Data Set (MDS - a standardized comprehensive assessment and care planning tool) dated 4/9/24, shows Resident 47 has a BIMS score of 6 (Brief Interview for Mental Status), which indicates severe cognitive impairment and only sometimes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 sufficient staffing to meet the needs of residents for 16 of 18 sampled residents (Resident 435, 55, 7, 33, 27, 20, 44, and nine Residents from a confidential resident meeting) when: 1. Resident 435 was observed waiting for their call lights to be answered for 30 minutes or longer. 2. Five of Eighteen sampled residents (Resident 55, 7, 33, 27, 20) reported waiting over one hour at times for staff assistance. 3. Resident 44 reported that certain Certified Nursing Assistants (CNA's) enter Resident rooms and cancel call lights without assisting Residents. 4. During a confidential resident meeting, nine of ten residents who attended stated call lights were not answered in a timely manner, which resulted in the resident's care needs not being met. These failures resulted in resident's not having their needs met in a timely manner which had the potential to result in physical and psychosocial harm. Findings: 1. During an observation on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide nursing staff with necessary competencies and skill sets to meet the care and services for resident needs for 17 of 18 sampled residents (Resident 435, 55, 7, 33, 27, 20, 44, 58, and nine Residents from a confidential resident meeting) when: 1. Resident 435 was observed waiting for their call lights to be answered for 30 minutes or longer. 2. Five of Eighteen sampled residents (Resident 55, 7, 33, 27, 20) reported waiting over one hour at times for staff assistance. 3. Resident 44 reported that certain Certified Nursing Assistants (CNA's) enter Resident rooms and cancel call lights without assisting Residents. 4. During a confidential resident meeting, nine of ten residents who attended stated call lights that were not answered in a timely manner, which resulted in the resident's care needs not being met. 5. Strong urine odor coming out form Resident 58's room. These failures resulted in resident's not having their needs met in a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to prepare and serve food that maintained an appetizing flavor, texture, appearance, and at a palatable (pleasant taste) temperature when 10 of 18 sampled residents (Residents 7, 13, and 8 Residents from a confidential resident meeting) when: 1. Resident 13 was served with a puree diet, the taste was so-so, and was cold. 2. Resident 7 stated the food was overcooked and did not have the appearance of what it should be. 3. Confidential resident interviews and resident council meeting minutes review indicated food was served cold. 4. The food on the test tray were mostly bland. These failures resulted in meals to be served cold, unpleasant, and not meet the resident food preference, which had the potential for residents to decrease meal intakes and have weight loss issues. Findings: 1. During a review of Resident 13's clinical record, the record indicated, Resident 13 was admitted to the facility on [DATE] with diagnoses which included end stage…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facility equipment was functioning when: 1. Air conditioner (AC) units to cool Rooms 11-18 were not working properly and needed replacement. 2. Toilet in room [ROOM NUMBER] was not secured to the floor. 3. Shower heads in shower rooms were leaking with low water pressure. 4. Sliding glass door track bent in dining room. 5. The door at the facility entrance would not close. 6. Leaking back flow pipe left corner of the building. 7. Floor of dietary department is leaking and flooding into basement These failures resulted in an uncomfortable warm temperatures, a fall with injury, and put all residents at risk for accidents and hazards. Findings: During a review of facility policy and procedure (P&P) titled Maintenance Service: Operational Manual - Physical Environment, dated 1/1/12, the P&P indicated the Maintenance Department maintains all areas of the building, grounds, and equipment to protect the health and safety of 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 ensure required corrective action was followed in the resolution of a grievance for one of 18 sampled residents (Resident 20). This failure had the potential for Resident 20 to feel her grievance was not managed properly, and therefore feel unsupported by the facility. Findings: A review was made of a facility policy titled, Theft and Loss, revised 7/11/17, which indicated that the facility investigates all reports of lost or stolen items and the Administrator (ADMIN) is to notify law enforcement within 36 hours of an incident involving theft of resident property with a value of $100 or more. Resident 20 was admitted to the facility with diagnoses which include heart failure (a condition in which the heart muscle cannot pump enough blood to meet the body's needs for nutrients and oxygen) and atrial fibrillation (the upper chambers of the heart beat fast and irregularly). During a concurrent observation and interview on 5/22/24 2:14 pm, Resident 20 stated approximately a week ago she had left her purse on the bed after…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, appropriate procedure was not followed in the execution of an out-of-facility transfer for one of four sampled residents (Resident 84). This failure could have resulted in Resident 84 and the Ombudsman (a resident advocate) not being notified and unaware of the impending transfer. Findings: A review was made of a facility policy titled, Discharge and Transfer of Residents, revised 2/2018, the purpose of which is to ensure that discharge planning is complete and appropriate. The policy directed that prior to discharge social service staff or nursing will provide the resident with a document, Notice of Proposed Transfer and Discharge, and a copy placed in the resident's medical record. Resident 84's admission record was reviewed which indicated she was admitted on [DATE] with diagnoses which included burns to the head, face, neck, right lower leg, and left hand; diabetes mellitus (a chronic condition wherein the body can't move sugar from the bloodstream into its cells 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, appropriate procedure was not followed in the execution of an out-of-facility transfer for one of four residents (Resident 84). This failure could have resulted in Resident 84 not being properly oriented to the purpose for the transfer and being unprepared, which could have resulted in uncertainty and anxiety. Findings: A review was made of a facility policy titled, Discharge and Transfer of Residents, revised 2/2018, the purpose of which is to ensure that discharge planning is complete and appropriate. The policy directed that prior to discharge social service staff or nursing will provide the resident with a document, Notice of Proposed Transfer and Discharge, and a copy placed in the resident's medical record. Resident 84's admission record was reviewed which indicated she was admitted on [DATE] with diagnoses which included burns to the head, face, neck, right lower leg, and left hand; diabetes mellitus (a chronic condition wherein the body can't move sugar from 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 regular (annual, quarterly, or as needed) IDT (an IDT is an interdisciplinary team of health care providers who have knowledge of the resident and his or her needs who is involved in making decisions about the resident's care), assessment for psychotropic medication (mind altering drugs) use and behavioral data for one of five sampled residents, Resident 53. This failure resulted in Resident 53 having a schizophrenia diagnosis (a mental health disorder that affects the way a person thinks, feels, and behaves and may include hallucinations) added to the medical records, in addition to anoxic brain injury (an injury to the brain due to lack of oxygen).The addition of the schizophrenia diagnosis was not documented by a psychiatric (mental health) physician or primary care physician. Findings: A review of Resident 53's records indicated she was admitted on [DATE], with diagnoses which included, Cerebral Infarction (blockage of blood vessels in the…

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

Based on observation, interview, and record review the facility failed to: 1. Provide the necessary care and services for dysphagia (difficulty swallowing foods or liquids) and gastrostomy feeding tube (or G-Tube, a medical device inserted into stomach surgically and used to provide liquid nourishment, fluids, and medications by bypassing oral intake) for one of two sampled residents (Resident 61), when Resident 61 was found to be lacking current Speech Therapy orders. This failure had the potential to lead to the Resident not attaining their highest level of practicable nutrition and emotional happiness. 2. Ensure safe assessment and measurement of the residents' gastrostomy feeding tube's gastric residual volume (the fluid left in the stomach after feeding or taking medication, measured to ensure that the stomach is emptying properly) during medication administration and bolus feeding (the administration of a limited volume of fluid formula over brief periods of time) for one out of two sampled residents (Resident 61). This failure had the potential to result in Resident 61…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement a plan of care to assess, monitor and modify approaches to pain management for one of three sampled residents (Resident 435). This resulted in Resident 435 to experience unrelieved pain. Findings: A review of the Pain Management policy, revised 05/25/23, indicated the goal for pain management will be resident centered and determined by the resident's acceptable level of pain. It is to help the resident maintain the highest level of well-being and to ensure that pain is assessed and managed. Licensed Nurse documentation should include pain assessments. Pain is managed according to professional standards of practice. A review of Resident 435's record indicated she was admitted to the facility on [DATE], with diagnoses which include blockage (unable to have bowel movements or digest food due to a blockage in the intestines) with surgical repair, gout (arthritis in the feet/toes), depression, and difficulty in walking. A review of…

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

Based on observation, interview, and record review, the facility failed to ensure safe practices in handling and storage of hazardous medications (drugs that pose short- or long-term harm upon exposure to human via skin or inhalation with required special handling by National Institute for Occupational Safety and Health, or NIOSH), when a hazardous liquid medication called Depakote solution (also called Valproic acid in liquid form; used to treat mood swings or seizure disorders) was stored unsafely in medication cart and was handled without use of gloves during medication administration. These failures could contribute to unsafe medication use and exposure of hazardous medication to staff and residents. Findings: During an observation and inspection of the facility's Medication Cart #4 at Station 2, accompanied by Licensed Vocational Nurse (LVN) TT, on 5/21/24 at 3:35 PM, three bottles of liquid Depakote medication (valproic acid) were stored inside the cart. One of the bottles had sticky pink colored spills on the outer surface. The valproic acid liquid bottles were not contained…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safe monitoring and accurate documentation of psychotropic medications (medication used for mood disorder and mental health) use including diagnosis and use of non-drug interventions (methods used to address other personal, emotional, or physical interventions before giving drugs) in two out of five sampled residents assessed for unnecessary drug use (Resident 61 and Resident 53) when: 1. Nursing interventions for non-drug approaches was not implemented for Resident 61's PRN (as needed) psychotropic medication called lorazepam (or Ativan, a drug used to treat anxiety). 2. Resident 53's medical record listed schizophrenia (a mental health disorder that affects the way a person thinks, feels, and behaves and may include hallucinations) as a diagnosis and indication for the use of Geodon (or Ziprasidone, a mind-altering drug used to control behavior or thought process) since admission when prior history did not confirm the diagnosis and no 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 ensure safe medication storage practices when: 1. The respiratory medication called Duoneb inhalation solution (or also known as Ipratropium and Albuterol inhalation solution, two drugs in one, used for better breathing and shortness of breath) stored in facility's Medication Cart #2 at Station 1 and Medication Cart #4 at Station 2, were not dated upon opening and; 2. Medication refrigerator at Station 2's medication room was heavily frosted and insulin (a biological product to treat blood sugar disease) and vaccine (a biological product used to prevent and protect from infections) product were stored in close proximity of the frosted area. These failed practices could result in spoiled, ineffective, and unsafe medication use in the facility. Findings: 1a. During an observation and inspection of station 2's medication cart #4, accompanied by Licensed Vocation Nurse TT (LVN TT), on 5/21/24, at 3:34 PM, multiple containers of respiratory medication known as Duoneb inhalation solution, for 3 different 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 facility document review, the facility failed to ensure federal regulations related to the education qualification requirements of the Certified Dietary Manager (CDM), were followed as outlined in the California Code, Health and Safety Code (HSC 1265.4). This failure had the potential to result in inadequate oversight of the food and nutrition services department associated with meal distribution accuracy, safe food handling and sanitation guidelines. Findings: According to the HSC 1265.4 a CDM, (4) Is a graduate of a dietetic services training program approved by the Dietary Managers Association and is a certified dietary manager credentialed by the Certifying Board of the Dietary Managers Association, maintains this certification, and has received at least six hours of in-service training on the specific California dietary service requirements contained in Title 22 of the California Code of Regulations prior to assuming full-time duties as a dietetic services supervisor at the health facility. On 5/21/24 at 8:30 AM an observation of the CDM's Credential…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 refuse (garbage) was stored in a sanitary manner when: 1. the lids to two of three outdoor refuse dumpsters did not close tightly, and 2. the area surrounding the dumpsters was not maintained in a sanitary manner to prevent pest/rodent infestation. These failures had the potential to attract pests and rodents that carry diseases. Findings: During review of the 2022 Food Code, United States (U.S.) Food and Drug Administration (FDA), Section 5-501.13: Receptacles, the document indicated receptacles and waste handling units for refuse, recyclables, and returnables and for use with materials containing food residue shall be durable, cleanable, insect- and rodent-resistant, leakproof, and nonabsorbent. During review of the 2022 Food Code, USFDA, Section 5-501.110: Storing Refuse, Recyclables, and Returnables, the document indicated refuse, recyclables, and returnables shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents. During review of the 2022 Food…

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

Based on interview and record review the facility failed to thoroughly investigate a staff to resident abuse allegation between Certified Nursing Assistant (CNA) A and Resident 1 when no further interviews were conducted by Admin with facility residents or staff after video footage was reviewed. This had the potential for ongoing staff to resident abuse in the facility. Findings: A review of a facility policy titled, Abuse and Neglect dated 11/18/21, indicated The Facility promptly reports and thoroughly investigates allegations of resident abuse, mistreatment, neglect, exploitation, abuse facilitated or enabled using technology, misappropriation of Resident property, injuries of an unknown source and suspicion of crimes. he Administrator (or designated representative) will provide for a safe environment for the Resident, as indicated by the situation. If the suspected perpetrator is an employee, the employee is immediately removed from Resident care duties and immediately suspended pending the outcome of the investigation, in accordance with Facility policy. The administrator (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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure steps were taken to protect one of three sampled residents' (Resident 1) personal property when Resident 1 ' s inventory list (an itemized list of the personal belongings and other items the resident brought with them to the facility), was not completed on admission or at any other time during her stay. This failure failed to honor Resident 1 ' s right to have their personal belongings protected and secured which had the potential to cause loss of personal property and affect her quality of life. Findings: A review of the facility ' s policy titled, Resident Rights dated 1/12/2012, indicated the purpose of resident rights is to promote and protect the rights of all residents at the facility. A review of the facility ' s policy titled, Personal Property dated 7/14/2017, indicated, The facility will make every effort to maintain the security of the residents ' property . Upon admission, the CNA/designee will conduct a personal property inventory…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an accurate and complete assessment for one of three sampled residents (Resident 1), when Resident 1 ' s pressure ulcer (localized skin and soft tissue injuries that form as a result of prolonged pressure exerted over specific areas of the body) to coccyx (a small area at the base of the spinal cord) and buttocks was not identified on their admission Minimum Data Set ( MDS, a complete clinical assessment). This failure had the potential for staff to not be fully informed of Resident 1 ' s skin condition to determine the need for further assessments and interventions that could result in delays in care and decline in Resident 1 ' s medical condition. Findings: A review of the facility ' s policy titled, admission Assessment revised 8/21/2020, indicated upon admission to the facility, licensed nursing staff will complete admission assessments on Residents. A review of the Minimum Data Set (MDS) Coordinator ' s job description indicated they are responsible for notifying and coordinating the Interdisciplinary Team…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 establish a system or process for recording the disposition for wasting (disposing of a controlled substance) narcotic patches when one of four residents was prescribed narcotic patches (Resident 1). Resident 1 was on hospice with fentanyl patches (a strong narcotic that comes in the form of a patch that is placed on the skin), ordered, and the disposition of the fentanyl patches that were removed from Resident 1's skin was not recorded by nursing staff who were unclear of the process for disposing of, and recording the disposition of, the narcotic patches. This failure had the potential to result in narcotic patches not being appropriately disposed of, due to lack of process for recording the disposition. The narcotic patches could possibly be inadvertently left on a resident while new patches are applied, or someone other than the person the narcotic patch was prescribed to, could procure a narcotic patch meant for disposition, which…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 consistently document the current oxygen delivery methods for two of three sampled residents (Residents 1 and 3) when: 1. Resident 1 ' s physician order for supplemental oxygen was not addressed in the resident ' s Care Plan and was inaccurately documented in the weekly nursing evaluation; 2. Resident 3 ' s oxygen delivery method was inaccurately documented in the weekly nursing evaluation. This failure had the potential to communicate inaccurate information which could have threatened the residents ' health and well-being. Findings: A facility policy, titled, Licensed Nurse Weekly Progress Notes, revised 10/1/12, was reviewed. It ' s stated purpose was to ensure the resident ' s Plan of Care effectiveness was reviewed to meet the resident ' s needs. The policy indicated the Licensed Nurse (LN) would have reviewed the Plan of Care on a weekly basis and documented the resident ' s response and progress towards the goal. A facility policy, titled,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Laboratory Services policy and procedure (P&P) for two out of two sampled residents (Resident 1 and Resident 2) when: 1a. The facility did not notify the physician when Resident 1 had abnormal laboratory results on 11/16/23. 1b. Laboratory services were provided to Resident 1 on 12/27/23 without a Physician ' s order. 2. The facility did not obtain Physician ordered laboratory services on two separate occasions for Resident 2. These failures had to potential to cause a decline in resident health status. Findings: 1a. During a review of the facility ' s P&P titled, Laboratory Services, revised 1/1/12, indicated, The Facility will provide laboratory services in an accurate and timely manner to meet the needs of residents per Attending Physician order. The P&P indicated, the Licensed Nurse (LN) would notify the Attending Physician of abnormal laboratory results by: Telephone/page or fax, with a date and time noted on results. The P&P indicated; LN would document in the resident ' s medical record the Attending…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the policy and procedure (P&P) for residents that received dialysis (procedure to remove waste and extra fluid from the body), were followed when: 1. Pre and Post Dialysis Assessments communication forms, that included an assessment of the resident before and after dialysis were not consistently performed and documented for two out of two sampled residents (Resident 1 and 2). 2. A recommendation made by the dialysis center, to discontinue a medication was not acted upon for one out of two sampled residents (Resident 2). 3. Dialysis dressings (bandages) had not been removed from the graft site (area of access for dialysis), within the required time frame for two out of two sampled residents (Resident 1 and 2). These failures placed residents who received dialysis at risk for the inability to attain or maintain their highest practicable level of physical, mental, and psychosocial well-being. Findings: 1. During a review of the facility's P&P…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were free from potential accidents and hazards by blocking access to one hand-pull (manual) fire alarm, emergency exits, and handrails (assist residents with walking). This failure put all residents at risk for falls and fire hazards. Findings: During an observational tour of the facility on 10/11/2023 at 8:03 am, the following safety issues were found: - Along the hallway wall between room [ROOM NUMBER] and the emergency exit door, an empty unmade bed, a Hoyer lift (allows staff to lift and transfer a resident with limited mobility), and a white plastic bedside portable toilet were pushed up against the wall and stuck out approximately 4 feet (ft) into the hallway. Along the hallway wall between rooms [ROOM NUMBERS], an empty unmade bed, a vitals cart, an unplugged television on top of an approximately 4 ft wide x 3 ft tall pillow cart, and an approximately 4 ft wide x 7 ft tall linen cart. Along the hallway wall between…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff wore hairnets when entering the kitchen area. This failure had the potential for hair to contact and contaminate food served to the residents. Findings: A review of the facility policy and procedure titled, Dietary Department-Infection Control For Dietary Employees, dated November 9, 2016, indicated personal cleanliness is required in sanitary food preparation areas. Clean hair - covered with an effective hair restraint while in all kitchen and food storage area. During an observation on 10/11/2023 at 7:50 am, hairnets were not available at the main kitchen entrance. During an observation on 10/11/2023 at 7:55, Dietary Supervisor (DS) entered the kitchen with no hair net. DS walked through the breakfast tray line area (where food was prepared). DS went into another room to get a hairnet. During an interview on 10/11/2023 at 9:02 am, with DS, confirmed there was no hair nets available for staff to put on before entering the kitchen area. DS stated hair nets should be available for staff to put them…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to treat three out four sampled residents (Residents 3, 4, and 5) with dignity and respect when long call light wait times were experienced. This failure resulted in feelings of neglect and anxiety for Residents 3, 4, and 5. Findings: A review of the facility's policy and procedure (P&P) titled, Communication Call System, revised 1/1/12, indicated, the purpose of the call system was To provide a mechanism for residents to promptly communicate with Nursing Staff and Nursing staff will answer call bells promptly, in a courteous manner. A review of the facility's P&P titled, Resident Rights-Quality of Life, revised 3/1/17, indicated Each resident shall be cared for in a manner that promotes and enhances the quality of life, dignity, respect, individuality and receives services in a person-centered manner, as well as those that support the resident in attaining or maintaining his/her highest practicable well-being. A review of the undated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 registry staff (staff that worked at the facility but were not employees) and housekeepers, who provided residents with cigarette (smoke) breaks, were knowledgeable of care planned (a plan that outlined a residents care) interventions (action taken, included in the residents care plan) for two out of two residents (Resident 1 and Resident 2) when Resident 1 and Resident 2 had been in a physical altercation, had interventions to be kept separated, and were outside in the resident smoking area at the same time. This failure placed Resident 1 and Resident 2 at risk for harm and abuse. Findings: During a review of the facility's policy and procedure (P&P) titled, Comprehensive Person-Centered Care Planning, revised 11/1/18, indicated, It is the policy of this Facility to provide person-centered, comprehensive and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents in order to obtain or maintain the highest physical,…

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

Based on interview and record review, the facility failed to maintain medical records that were complete for one out of two sampled residents (Resident 1) when: 1. The medical record did not contain Alert Notes (a note that was written by Licensed Nurses (LN), each shift after Resident 1 was involved in a Resident-to-Resident altercation that described Resident 1's condition. 2. The medical record did not contain a Change of Condition note that indicated the physician had been notified when Resident 1 was struck in the face by another resident. 3. The LN did not document a physical assessment of Resident 1 after Resident 1 was stuck in the face by another resident. This failure had the potential for confusion regarding Resident 1's health status and for potential health decline to go unnoticed. Findings: 1. During a review of the facility's P&P titled, Alert Charting Documentation, revised 1/1/12, indicated, Notes pertaining to the change of condition will be maintained in the resident's medical record as narrative notes and Alert charting is required for but not limited to the…

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

Based on interview and record review, the facility failed to ensure that residents received food that accommodated their schedule, needs, preference, and request for one of 8 sampled residents (resident 2), when Resident 2 was scheduled to be out of the facility for dialysis, was unable to consume food for lunch, and was not provided food upon return to the facility. This failure resulted in loss of nutritive sustenance with the potential to contribute to a decline in nutritional status, weight loss, and an overall decrease in health and wellbeing. Findings: A review of Resident 2's clinical record indicated initial admit to the facility was on 4/3/23 with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD, chronic progressive inflammatory lung disease that causes obstructed air flow), End Stage Renal Disease, Type 2 Diabetes Mellitus with Hyperglycemia. The most recent Minimum Data Set (MDS, a standardized comprehensive assessment tool), dated 7/3/23, indicated that Resident 2 had a Brief Interview for Mental Status (BIMs, cognitive scoring system) 11 which equates…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and evaluate that Licensed Nurses (LN) were competent and had the appropriate skills to provide quality care to 3 of 7 sampled residents (Residents 2, 4, and 6) when: 1. LN B had not followed the physician ordered hypoglycemic protocol (hypoglycemia is a life-threatening condition where the body's blood sugar is dangerously low and can cause lightheadedness, sweating, hunger, loss of consciousness, seizures, coma and death), for Residents 2 and 4, when their blood sugars were less than 70 (normal range is 80 to 130 for those who have diabetes, according to the American Diabetes Association), and she had not notified their physician. 2. LN B was not familiar with the physician ordered hypoglycemic treatment for Residents 2 and 4, when their blood sugars were dangerously low and instead of following the physician ordered treatment, she used her own judgement on how to correct the resident's hypoglycemia. LN B then had not followed through by…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 4 of 7 sampled residents with snacks to eat in the evening when the facility's kitchen was closed. (Resident 1, 2, 3, and 4) This failure had the potential to for residents to go hungry and have dangerously low blood sugar levels at night, which could negatively impact their health, emotional and psychosocial well-being. Findings: During a review of the facility's policies and procedures (P&P) titled, Nourishment and Snacks, revised 4/4/14, indicated, Individual and/or bulk snacks are available at the nurse's station for consumption by residents. Additional snacks may be made available upon resident request. The P&P indicated snacks would be provided to residents who were on a controlled carbohydrate diet (diabetic diet). During an interview on 8/24/23 at 10:15 am, with Director of Nurses (DON), DON stated there had been an issue with facility staff eating the resident's snacks during the evening shifts. 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 observations, interviews and record reviews, the facility failed to ensure professional food storage and sanitation practices were in place for resident food items when the unit refrigerator, located in the central supply room at Nurse Station 2, was dirty, resident food items were not labeled with a use by date, and staff food items were spoiled. This failure had the potential to result in causing the residents' to become ill from bacteria and mold on their food by being stored in a dirty refrigerator. Findings: A review of the Food and Drug Administration (FDA) policy, dated 2022, indicated, 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. During a review of the facility's policy and procedure (P&P) titled, Dietary Department-General , revised 6/1/14, indicated, The primary objectives of the dietary department include .maintenance of standards for sanitation and safety . During a review of the facility's P&P titled. Food Brought in by Visitors , revised…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and record reviews, the facility failed to ensure professional food safety and sanitation practices were in place when the Dietary [NAME] (DC) did not perform hand hygiene (washing hands) after using a personal cell phone in the food prep area. This failure had the potential to result in cross contamination (means the transfer of harmful substances or disease-causing microorganisms to food by hands) for a facility with a census of 85 residents who consumed food prepared in the facility. Findings: A review of the facility ' s policy and procedure (P&P) titled, Dietary Department- Infection Control for Dietary Employees, revised 11/9/16, the P&P indicated, handwashing would be done Immediately before engaging in food preparation, including working with non-prepackaged food, clean equipment and utensils . The P&P indicated dietary staff would wash hands After engaging in any other activities that contaminated the hands. During a concurrent observation and interview on 8/10/23 at 9:40 am, the DC was observed in the food prep area of the facility ' 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 observations, interviews and record review the facility failed to ensure meals met resident needs for four out of five sampled residents (Residents 1, 2, 3, and 4) when food was not palatable (did not taste good, had no flavor, or was burnt). This failure had the potential to result in decreased resident meal intakes, negatively impact their nutritional status, negatively impact their overall health status, and quality of life. Findings: During a review of the facility ' s policy and procedure (P&P) titled, Dietary Department-General, revised 6/1/14, the P&P indicated, dietary objectives included Preparation and provision of nutritionally adequate, attractive, well-balanced meals . The P&P indicated, The dietary department is responsible for establishing a program that meets the nutritional needs of the residents . A review of Resident 1 ' s records indicated admission to the facility on 4/2/12 with the diagnosis of type 2 diabetes mellitus with diabetic neuropathy (diabetes that included nerve damage). Resident 1 had good cognition (ability to remember, think, and recall…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, and record reviews, the facility failed to accommodate food preferences (likes and dislikes) for two out of four sampled residents (Resident 1 and Resident 2) when: 1. Resident 1 and Resident 2 ' s vegetables were not served in a bowl. 2. Resident 2 was served cooked carrots. This failure had the potential to result in decreased resident meal intakes, negatively impact nutritional status, overall health status, and quality of life. Findings: During a review of the facility ' s policy and procedure (P&P) titled, Dietary Profile and Resident Preference Interview, revised 4/21/22, the P&P indicated, The Dietary Department will provide residents with meals consistent with their preferences and Physician order as indicated on the tray card. 1. A review of Resident 1 ' s records indicated admission to the facility on 4/2/12 with the diagnosis of type 2 diabetes mellitus with diabetic neuropathy (diabetes that included nerve damage). Resident was had good cognition (ability to remember, think, and recall information) and was her own responsible party (RP,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, and record reviews the facility failed to provide regular maintenance to the portable air conditioner (PAC), located in the dry food storage area of the Certified Dietary Manager ' s (CDM) office, when the PAC filter was not cleaned in a timely manner resulting in a room temperature of 79 degrees Fahrenheit (a unit of measure, °F). This failure had the potential to cause bread products to mold and could negatively impact the provision of safe food to residents living in the facility. Findings: 2022 FDA Food Code - 4-501.11 Good Repair and Proper Adjustment. (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. FDA Food Code 2012, 6-501.11 Repairing. Physical Facilities shall be maintained in good repair. During a review of the facility ' s policy and procedure (P&P) titled, Maintenance Service, revised 1/1/12, the P&P indicated, The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 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, four out of four residents (Residents 1, 2, 3, and 4) were not cleaned and changed from incontinent episodes in a timely manner which had the potential for the residents to feel their dignity was not maintained or respected. Findings: A review was made of a facility policy titled, Incontinence Care, revised 9/1/14: Residents who are incontinent of urine, feces, or both, will be kept clean, dry and comfortable; Incontinence care is provided when the resident is wet or soiled. An interview was conducted with Resident 1 on 7/6/23 7:25 pm. Resident 1confirmed that she was incontinent of urine and stated, it takes forever for them to answer a call light, that it can take up to 45 minutes for staff to respond to the call light and that she is left in wet briefs and gets rashes and that this has been an ongoing situation. A review was made of an admission record dated 8/26/19 wherein Resident 1 was admitted with diagnoses which included cerebral infarction (the brain's blood supply is interrupted, preventing brain tissue from getting oxygen and…

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

Based on interview and record review, the facility failed to develop a comprehensive patient-centered care plan when a plan addressing urinary incontinence was not developed for one out of four residents (Resident 3); this failure had the potential for Resident 3 not receiving the care and services necessary to maintain skin integrity and prevent tissue break down. Findings: An interview was conducted with Resident 3 on 7/6/23 7:35 pm. Resident 3 stated that she is incontinent and response time to change her varies from a few minutes to long waits, and that she has developed rashes in the past from exposure to urine. A review was made of Resident 3's admission record dated 4/10/23 wherein the resident was admitted to the facility with diagnoses including a fractured left fibula (a broken bone in the calf), chronic respiratory failure (a condition that results in the inability to effectively exchange carbon dioxide and oxygen in the lungs), atrial fibrillation (a disorder of the heart that effects its ability to pump normally), diabetes (a blood sugar disorder), and morbid obesity…

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