Veterans Home Of California - Chula Vista

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a person-centered care plan for weight loss was updated for one of 44 sampled residents (Resident 20). This failure had the potential for Resident 20 not to receive nutrition interventions and treatments according to evaluation of his needs and contributing to continued weight loss. Cross reference F692 Findings: During a review of Resident 20's admission Face Sheet Record (demographics), [undated], the Face Sheet indicated Resident 20 was admitted on [DATE] with diagnoses of Hypertension (HTN, high blood pressure), rheumatoid arthritis (a chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility), and chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing). During a review of Resident 20's Minimum Data Set (MDS, a resident assessment tool), dated 12/5/2024, the MDS indicated the Resident 20 had a BIMS (brief interview of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a comprehensive systematic approach for monitoring nutrition interventions was implemented for one of 44 sampled residents, (Resident 20), who experienced an unplanned unintentional weight loss of 7.79% in six months, according to facility policy. This failure had the potential for Resident 20 to experience additional unintentional weight loss, which could lead to further decline in the resident's health and nutrition status. Cross reference F657 Findings: During a review of an article titled, 2002 American Academy of Family Physicians Journal, indicated, Involuntary weight loss can lead to muscle wasting, decreased immunocompetence, (the ability for the body to develop an immune response) depression and an increased rate of disease complications. Research has shown institutionalized elderly patients who lost 5 percent of their body weight in one month were found to be four times more likely to die within one year.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safe and effective pharmaceutical services for a universe of 103 residents when: 1. During an inspection of one of two medication rooms, outdated Procrit (drug to treat low red blood cell count), Mantoux (diagnostic test to detect tuberculosis infection which is a lung infection) vial, and insulin (drug to manage blood sugar levels) pen were observed stored and available for resident use. This failure had the potential for residents to receive outdated and/or ineffective medications which could result in adverse clinical outcomes. 2. During an inspection of one of two medication carts, one expired nitroglycerin (drug to manage chest pain) vial was observed stored and available for resident use. This failure had the potential for residents to receive outdated and/or ineffective medications which could result in adverse clinical outcomes. 3. For Resident 5, the facility could not demonstrate controlled drug (narcotics with potential…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 did not ensure the medication error rate was less than 5% when three errors for Resident 9 and Resident 87 occurred out of 42 opportunities for a medication administration error rate of 7.14%. For Resident 9, the medication glipizide (drug to manage blood sugars) was not administered 30 minutes before meals. For Resident 87, one medication was omitted, and the medication fexofenadine (drug to manage allergies) was given to the resident at the same time as fruit juice. This failure had the potential to expose residents to preventable medication errors which could result in adverse health outcomes. Findings: a. During a concurrent observation and interview on 1/28/2025 at 9:27 a.m., Licensed Vocational Nurse 2 (LVN 2), at the medication cart outside of Resident 9's room, the medication glipizide was prepared at the medication cart. LVN 2 acknowledged glipizide tablet was poured into the medication cup for Resident 9. During an observation on 1/28/2025 at 9:40 a.m., in Resident 9's room, LVN 2 administered glipizide to…

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

Based on observation, interview, and record review, the facility failed to ensure medications were appropriately labeled in accordance with accepted standards of practice and/or manufacturer's instructions when: 1. During an inspection of one of two medication rooms, one outdated insulin vial was stored and available for resident use. 2. During an inspection of one of two medication rooms, a bulk bottle of atovaquone (anti-infective drug) oral suspension (liquid) for Resident 39 was not stored in accordance with manufacturer's instructions and available for resident use. These failures had the potential for residents to receive outdated and/or ineffective medications which could result in adverse clinical outcomes. Findings: 1. During a concurrent observation and interview on 1/27/2025 at 2:48 p.m., an inspection of the Unit 700 Medication Room was conducted with Pharmacist 1 (RPH 1). During a concurrent observation and interview on 1/27/2025 at 3:11 p.m., in the medication room, an insulin vial was observed stored with a pharmacy label indicating Do Not Use After 01/22/25. RPH 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a dental appointment was scheduled for one of 44 sampled residents (Resident 72). This failure had the potential to result in Resident 72 experiencing infection, pain, or complications from ill-fitting dentures. Findings: During a review of Resident 72's Face Sheet (demographics), dated 1/30/2025, the Face Sheet indicated Resident 72 was admitted to the facility on [DATE] with diagnosis of dysphagia (difficulty swallowing foods and liquids). During a concurrent observation and interview on 1/28/2025 at 10:02 a.m., with Resident 72, Resident 72 was observed without any teeth or dentures in his mouth. Resident 72 stated he had dentures but did not wear them because the dentures were uncomfortable. Resident 72 stated, I haven't been seen by dentist in a while. During a concurrent interview and record review on 1/29/2025 at 2:45 p.m. with Registered Nurse 4 (RN 4), RN 4 stated Resident 72 had not been to the dentist since 10/23/2023.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 food was served at an acceptable temperature to be appetizing for residents according to the facility's resident council and the facility policy. This failure had the potential to affect meal and food intake which could impair the nutrition status of the residents. Findings: During a review of the facility's menu titled, January 26, 2025-February 01, 2025, the menu for Tuesday 1/28/2025 indicated, the lunch meal for a Regular diet included, Carrot Raisin Pineapple Salad, Carne [NAME]/Soft Tortilla, Pinto Beans/Corn Muffin, Tomato/Onion/Cilantro, Sour Cream/Salsa and Chocolate Cake with Icing for dessert. During a concurrent test tray observation and interview on 1/28/2025 at 12:50 p.m. in the 1000 Unit pod common dining area, the meal cart left the kitchen and arrived at the Unit at 12:18 p.m. The entrée of carne [NAME] with tortilla was 128 degrees Fahrenheit (F- measurement of temperature) and the 8-ounce carton of 2% milk was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure safe infection control practices were followed when: 1. Enhanced Barrier Precautions (EBP - infection control practice that uses PPE-personal protective equipment to reduce the spread of bacteria) was not followed for Resident 84 during perineal hygiene care (cleaning of genital area), medication administration, and tube feeding (liquid nutrition delivered through a tube that is inserted through the skin into stomach) administration. 2. Enhanced Barrier Precautions (EBP-infection control practice that uses PPE-personal protective equipment to reduce the spread of bacteria) was not followed for Resident 25 during medication administration via tube feeding (liquid nutrition delivered through a tube that is inserted through the skin into stomach). 3. An opened single-use syringe labeled sterile was observed attached with a rubber band to a gabapentin (drug to manage chronic pain condition) medication bottle for Resident 51. 4. One…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement an accurate comprehensive person-centered care plan for one of three sampled residents (Resident 1), when Resident 1's exhibited behaviors were not monitored or documented. This failure had the potential to result in Resident 1 not receiving interventions necessary to maintain mental and psychosocial well-being. Findings: During a review of Resident 1's admission Face Sheet Record (face sheet), dated 10/13/2023, the face sheet indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses which included Major Depressive Disorder (mood disorder causing persistently low or depressed mood and a loss of interest in activities), Panic Disorder (disorder with unexpected and repeated episodes of intense fear), and Post-Traumatic Stress Disorder (disorder that develops in some people who have experienced a shocking, scary, or dangerous event). During a concurrent observation and interview on 9/30/2024 at 10:45 a.m. with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, assessment tool to guide care) assessments were transmitted to the Centers for Medicare and Medicaid Services (CMS) in a timely manner by: 1. Failing to transmit the completed annual MDS assessment within 14 days after completion for one of four unsampled residents (Resident 65). 2. Failing to complete and transmit the MDS discharge assessment for one of four unsampled residents (Resident 112) in a timely manner. 3. Failing to transmit the completed MDS discharge assessment within 14 days after completion for one of four unsampled residents (Resident 43). These failures resulted in the MDS discharge assessments not being received by CMS for quality measure monitoring and had the potential to result in the residents not receiving timely and appropriate care based on changes in their health care status. Findings: 1. During a review of Resident 65's face sheet (resident demographics), the face sheet indicated Resident 65…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 to ensure the charge nurse key sets for Unit 300, 700, and 1100 were kept in a location not accessible by unlicensed staff. This failure had the potential for unauthorized staff to have access to the medication rooms and had the potential for drug diversion (the illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber). Findings: During a concurrent medication storage observation and interview on 3/7/2024 at 9:53 a.m. with the Licensed Vocational Nurse 2 (LVN 2), in Unit 700, LVN 2 was observed retrieving a key set from a black drawer underneath a desk in the nursing station. Upon further inspection of the black drawer, 2 more key sets were found in the top drawer. LVN 2 stated the drawer had no locking system. LVN 2 stated one key set is for Unit 700 which had the keys for the Unit 700's medication room, emergency kit (E-kit, a container with emergency medications including pain and antibiotic medications) cabinet, the oxygen room, and storage room. LVN 2 stated…

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

Based on observation, interview, and record review the facility failed to ensure the regular menu was followed as printed. This failure had the potential to alter the nutritional value of the meal, which could decrease food intake and compromise the residents' nutritional status in a facility population of 113 residents. Findings: During a concurrent observation and interview on 3/5/2024 at 11:32 a.m. in the kitchen of the lunch tray line, the lunch meal trays were observed with white rice being served as the alternate rice on a regular diet tray and not rice pilaf as listed on the menu. The [NAME] Specialist 1 (CS1) stated that she had forgotten to make the rice pilaf. Three meal carts with 60 lunch trays were served without the rice pilaf. During a review of the Diet Spreadsheet, dated 2/24/2024, the Diet Spreadsheet indicated, Day 3 Regular Lunch Alternate [NAME] Pilaf. During a review of the Rice Pilaf Recipe, the recipe indicated .½ cup of rice pilaf provide 114 calories, 20 grams of carbohydrates, 2.86 grams of protein, and 25 milligrams (mg) of calcium. During a review of the…

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

Based on observation, interview, and record review the facility failed to ensure safe and sanitary conditions were maintained in the food and nutrition services department for food safety and storage according to standards of practice and facility policy when: 1. Three ice machines were dirty with light brown, grayish colored residue inside the ice chutes that flows into the ice bin. 2. Kitchen Cutting boards were found overworn, discolored, scratched, and scored. 3. Kitchen Storage bins for serving utensils were dirty and contained debris. 4. A mixing blade attachment was found soiled with dried brown debris in the kitchen. 5. The electrical outlet on the food preparation island in the kitchen was missing a cover and had a dark colored stain around the outlet. 6. Perishable food items in a Reach-in refrigerator and a Walk-in refrigerator were mislabeled and were not disposed of by their use-by-dates. These failures had the potential to expose residents to food contamination, resulting in food borne illnesses for all residents who consume food from the kitchen for a facility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 essential kitchen equipment were maintained in a safe, operating, and fully functioning manner when: 1. The water at the hand wash sink by the entrance to the kitchen took an extended period to reach 100 degrees Fahrenheit (F, a scale for measuring temperature), 2. The high temperature dish machine did not come to the required final rinse temperature for sanitation, and 3. There was condensation dripping from a ceiling pipe on cases of milk cartons in a walk-in refrigerator. These failures had the potential to impact the ability of dietary staff to prepare, store, and serve food in a safe and sanitary manner. Findings: 1. During the initial kitchen tour observation on 3/4/2024 at 8:50 a.m., an observation of the hand wash sink near the entrance of the kitchen was conducted. The hand wash sink took 67 seconds to reach a temperature of 100 degrees F. During an observation on 3/4/2024 at 2:45 p.m., an observation of the hand wash sink near the entrance of the kitchen was conducted. The hand wash sink took…

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

2. During a concurrent observation and interview on 3/4/2024 at 10:20 a.m. with Resident 76, in Resident 76's room, there was an area above the corner desk where purple and white paint was peeling off from the ceiling and the wall. Resident 76 stated she had reported the peeling paint to the staff about a month ago. Resident 76 stated the peeling paint was getting bigger every day. Resident 76 stated the peeling paint bothered her because it looked like water damage, and she was concerned about the area having mold. During an interview on 3/4/2024 at 3:12 p.m. with Office Assistant (OA), OA stated she saw the peeling paint on Resident 76's room last week and put in a Sprocket Work Order (a document that includes details of maintenance tasks and outlines a process for completing those tasks). During a review of the Sprocket Work Order dated 2/29/2024, the order indicated a work order description of paint/patch repair in Resident 76's room. During an interview on 3/5/2024 at 3:39 p.m. with the Chief of Plant Operation (CPO), the CPO stated water got behind the paint and thus the paint…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Quarterly Minimum Data Set (MDS, assessment tool to guide care) was completed within 14 days of the Assessment Reference Date (ARD, end-point date for the observation periods of the assessment) for one of 25 sampled residents (Resident 16). This failure had the potential to result in Resident 16 not receiving timely and appropriate care based on changes in his health care status. Findings: During a review of Resident 16's face sheet (resident demographics), the face sheet indicated Resident 16 was admitted to the facility on [DATE] with a diagnosis of hemiplegia (paralysis of one side of the body) following cerebrovascular disease (CVD, condition that affects blood flow to brain). During a concurrent interview and record review on 3/7/2024 at 9:40 a.m. with MDS Coordinator (MDSC), Resident 16's quarterly MDS indicated, the ARD was 12/22/2023 and the MDS completion date was 3/5/2024. MDSC stated MDS assessments were usually completed within 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 F919 483. the call system must be accessible to residents in their beds. Based on observation, interview, and record review, the nursing staff needed to ensure the call light was within reach of Resident 108. This deficient practice ZjQcmQRYFpfptBannerStart ZjQcmQRYFpfptBannerEnd Based on observation, interview, and record review, the facility failed to develop a care plan (resident demographic) for mobility related to right ankle fracture for one of 25 sampled residents (Resident 108). This failure had the potential to result in a decline in physical mobility for Resident 108. Findings: A review of Resident 108's face sheet (resident demographics) indicated Resident 108 was admitted on [DATE] with diagnoses of fracture to upper and lower end of right fibula (calf bone), difficulty in walking and pain. During a review of the quarterly Minimum Data Set (MDS-a standardized assessment and care screening tool) for Resident 108, dated 12/20/2023, indicated that Resident 108 was using a walker as a mobility device,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 severe weight loss of 14.75% (percent) in six months, was assessed for one of four unsampled residents (Resident 17). In addition Resident 17's weight loss was not addressed according to standards of practice for weight loss. This failure had the potential to result in functional decline, infections, decubitus ulcers (injury to skin, tissue from prolonged pressure), exacerbation of cognitive and mood disorders, and an increased risk of death for Resident 17. Findings: During a review of Resident 17's Face Sheet, (resident demographics), dated 3/7/2024, the face sheet indicated, Resident 17 was admitted to the facility on [DATE] with diagnoses including hyponatremia (low sodium in the blood), nutritional deficiency (lack of sufficient nutrients in the body), constipation (difficulty having bowel movements), iron deficiency anemia (lack of iron causing the body to produce red blood cells) and hypertensive heart disease with heart…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 hospice nursing and aide notes, reflective of assessments and care provided, were obtained from the hospice (end of life care) provider for two of three sampled residents (Residents 66 and 78) for hospice review. This failure had the potential for inconsistent or inadequate communication in the coordination of care for the residents. Findings: 1. During a review Resident 78's Physician's orders, dated 9/26/2023 the Physician orders indicated Resident 78 was admitted to (name of agency) hospice on 9/23/2023, with a terminal (can't be cured) diagnosis of heart failure. During a review of Resident 78's hospice binder, (book of documents provided to the facility by the hospice agency), the binder contained a Table of Contents, which was a list of items expected to be found in the binder. Included in the Table of Contents was, Hospice Nursing Clinical Notes, and Hospice Aide Visit Notes. The binder also had sign-in sheets indicating when a nursing or aide visit had occurred. The sign-in sheets, between 12/27/2023 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 F919 483. the call system must be accessible to residents in their beds. Based on observation, interview, and record review, the nursing staff needed to ensure the call light was within reach of Resident 108. This deficient practice ZjQcmQRYFpfptBannerStart ZjQcmQRYFpfptBannerEnd F919 483. the call system must be accessible to residents in their beds. Based on observation, interview, and record review, the nursing staff needed to ensure the call light was within reach of Resident 108. This deficient practice ZjQcmQRYFpfptBannerStart ZjQcmQRYFpfptBannerEnd Based on observation, interview, and record review the facility failed to ensure the call light was within reach for one out of 25 sampled residents (Resident 108). This failure resulted in Resident 108 not able use the call light for staff assistance, for care and services when needed and had the potential for accidents such as falls and injuries. Findings: During a review of Resident 108's face sheet (resident demographics), [undated], the face sheet…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure licensed nurses administered gabapentin (used to treat pain) medication at the correct time (9 PM), as ordered by the physician for 1 of 3 sampled residents (Resident 1). This failure had the potential for Resident 1 to have unresolved pain and disruption of sleep. Findings: An onsite visit was made to the facility on 2/14/2024 in response to a facility reported incident. During a review of the face sheet (demographics), the face sheet indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses which included unspecified pain. During a review of a physician's order, dated 2/1/2024, the order indicated, Gabapentin 300 MG (milligrams) capsule .Take one (1) capsule by mouth twice a day at 09:00 (9 AM) and 21:00 (9 PM) for right shoulder pain . During a review of the February 2024-Medication Administration Record (MAR), dated February 2024, the MAR indicated the 2/1/2024 order for gabapentin 300 mg capsule was being…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement their policy and procedure for reporting suspected financial abuse, for one of three sampled residents (Resident 1), within 24 hours. This failure resulted in a year long delay of California Department of Public Health (CDPH) oversight and investigation of the suspected abuse, placing other residents at risk for potential financial abuse. Findings: On 7/19/2023, the facility sent an e-mail to CDPH as a courtesy report of their notification to APS (Adult Protective Services) for the failure of Resident 1's DPOA (Durable Power of Attorney- person legally appointed to manage another person's finances) to pay monthly residential fees, and that an SOC 341 (Report of Suspected Dependent Adult/Elder Abuse) had been submitted to APS. A review of Resident 1's Face Sheet indicated she was admitted to the facility on [DATE] with diagnoses which included need for assistance with personal care. A review of the MDS (Minimum Data Set- an assessment tool…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 personal belongings were secured for one of three Residents (1) when another Resident (2) occupied Resident 1's room while he was at the hospital. This failure resulted in Resident 1's personal belongings being left unsecured in his room with the potential to be lost or stolen. Findings: A review of Resident 1's Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. During an interview with the Standards Compliance Coordinator (SCC) on 7/26/23 at 10 AM, the SCC stated Resident 1 was transferred to the hospital on 7/14/23 and had not yet returned to the facility. During an observation in Resident 1's room, and a concurrent interview with Licensed Vocational Nurse (LVN) 1 on 7/26/23 at 1:15 PM, Resident 2 was observed sleeping in the bed. LVN 1 stated Resident 2 had been temporarily moved to this room while his roommate was on isolation. LVN 1 pointed to a desk in the corner and stated Resident 1's belongings were…

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

Based on observation interview and record review, the facility failed to implement its policy for Suicide Prevention, for one of three Residents (1), when sharp objects remained in Resident 1's room after staff conducted a safety sweep. This failure resulted in Resident 1 having access to sharp objects, with the potential to use them for self-harm. Findings: A review of Resident 1's Face Sheet dated 5/24/21, indicated Resident 1 was admitted to the facility with diagnoses which included major depressive disorder. A review of the Social Work Progress Note dated 7/14/23, indicated, Per resident, he has suicidal thoughts 2 to 3 times a week . A review of the facility Investigation Report dated 7/14/23, indicated, The resident was placed on enhanced monitoring and staff searched his room for any blunt or sharp instruments, and none were found. The call light cord and other cords were removed . There was no documentation that glass objects had been removed from Resident 1's room. During an observation of Resident 1's room, with Licensed Vocational Nurse (LVN) 1 on 7/26/23 at 1:15 PM,…

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