Claremont Manor Care Center

During a concurrent observation and interview on 3/10/2026 at 9:20 AM with the Kitchen Cook, five half gallon containers of milk with a best used by date of 2/26/2026 were found in the kitchen refrigerator. The Kitchen [NAME] stated expired milk should not be kept in the refrigerator, as it could be mistakenly served to the residents and potentially cause illness.During an interview on 3/11/2026 at 9:15 AM with the Director of Dining Services (DDS), DDS stated expired food items, including milk, must be discarded because retaining them in the refrigerators poses a potential health hazard to the residents.During a review of the facility's policy and procedure (P&P) titled, Production, purchasing, storage, the P&P indicated all food and supplies used in food preparation shall be stored in such a manner as to prevent contamination and maintain safety of the food for human consumption. The refrigerated storage life of food uses manufacturers expiration date and or milk should be plus three days after opening or by expiration date, if sooner.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow infection control practices and ensure a safe, sanitary environment for two of two sampled residents (Resident 5 and Resident 15).This deficient practice had the potential to cause healthcare associated infections that can cause pain and discomfort for residents.Findings:1. During a review of Resident 5's admission Record (AR), the AR indicated the facility admitted Resident 5 on 8/23/2017 with diagnoses that included hypertensive heart disease with heart failure (when long-term high blood pressure [hypertension] makes it harder for the heart to pump blood making it more difficult for the heart muscle to relax) and cerebral infarction (stroke).During a review of Resident 5's Minimum Data Set (MDS- a resident assessment tool), dated 12/3/2025, the MDS indicated Resident 5 had intact cognition and was dependent on staff for showers/bathing self and toileting hygiene.During an observation on 3/11/2026 at 9:37 AM, Licensed Vocational…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prevent one of three sampled residents (Resident 1) from being verbally abused when Resident 2 threatened, cursed, and yelled at Resident 1.This failure resulted in Resident 1 being scared and angry and had the potential to result in Resident 1 experiencing feelings of decreased self-worth.Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 11/10/2023 with diagnoses including chronic obstructive pulmonary disease (a group of lung diseases that cause long-term breathing problems) and muscle weakness (a reduced ability of one or more muscles to exert force).During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 5/14/2025, the MDS indicated Resident1's cognitive (the ability to think and process information) skills for daily decision making were intact. The MDS indicated Resident 1 was independent (the resident completes the activity by themselves with no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 allegation of abuse for one of three sampled residents (Resident 1) to the California Department of Public Health (the Department) within two hours, in accordance with the facility's policy and procedure (P&P), titled Adult Abuse, revised April 2018. This failure resulted in the delay of notification to the Department and had the potential for Resident 1 to be subjected to abuse while at the facility. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 4/3/2025, with diagnoses including urinary tract infection (UTI, an infection in any part of the urinary system, including the kidneys, bladder, or urethra), metabolic encephalopathy (brain disease that alters brain function or structure), and hypertension (high blood pressure). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 4/10/2025, the MDS indicated Resident 1 was severely impaired in cognitive skills (the ability to make daily decisions). The MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an alleged violation involving abuse, for one of four sampled residents (Resident 1), was reported immediately but no later than 2 hours after the allegation was made, to the facility's administrator (ADM) and other proper authorities as indicated in the facility's policy and procedure (P&P), titled, Adult Abuse. This deficient practice resulted in the delay of notification to the State Agency (CDPH, California Department of Public Health) and the Ombudsman (an official, public advocate, helps to resolve issues between parties through various types of informal mediation) and had the potential to result in compromised safety to Resident 1 due to the facility's failure to take corrective actions to prevent further potential abuse. Findings: During a review of Resident 1's admission Record (AR), the AR indicated, Resident 1was admitted to the facility on [DATE] with multiple diagnoses including Alzheimer's disease (a disease characterized by a…

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

Based on observation, interview, and record review, the facility failed to have an effective pest control program, to prevent cockroaches in one of one kitchen for a facility licensed for a 59-bed count. This deficient practice had the potential to expose 38 residents currently residing in the facility to foodborne illness. Findings During a concurrent observation and interview on 2/11/25 at 1:15 p.m. while in the kitchen with the head chef (HC), HC stated he has only been employed at the facility for a few weeks. HC stated he doesn't know the last time the kitchen had a deep cleaning for the floors and all areas of the kitchen. HC stated the kitchen crew does daily sweeping and mopping two times (once during the day and once in the evening after dinner). During the tour of the kitchen, in the back of the cooking areas, there was grease and dirt build up observed on the pipes. The kitchen exhaust hood was observed with grease and dirt build up on the overhead fire sprinklers. During an observation on 2/11/25 at 1:40 p.m. while in the kitchen near the dishwashing area, 4 gray colored…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 develop and implement an individualized person-centered care plan (CP), for four of four sampled residents (Resident 37, Resident 27, Resident 6, and Resident 5), as indicated in the the facility's policy and procedure (P&P), tilted, Care Plan, by failing to, a. Develop a care plan (CP) for Resident 37 when there was a change in skin condition on 1/11/2025. b. Develop a CP for Resident 27 for anticoagulant (class of medication that help prevent blood clots from forming in the heart and blood vessels) use when Resident 27 received Eliquis (medication used to prevent blood clots) tablet 2.5 milligrams (mg, unit of measurement) by mouth twice a day. c. Develop a CP for Resident 6 for antipsychotic (class of medications used to treat symptoms such as hearing voices and hallucinations) use when Resident 6 received Quetiapine (antipsychotic medication to that helps regulate mood, behavior, and thoughts) 25 mg by mouth at bedtime for poor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 who were at risk for skin breakdown and pressure injuries (PIs, localized damage to the skin and underlying soft tissue, usually occurring over a bony prominence or related to medical devices) received treatment and services to prevent skin breakdown for two of three sampled residents (Resident 32 and Resident 37) who had PIs by failing to ensure, A. Resident 32's LAL mattress (LAL Mattress -air filled mattress used to relieve pressure) was set according to Resident 32's weight of 138 pounds (lbs.). Resident 32's LAL mattress was set at 550 pounds (lbs.). B. For Resident 37, 1.The facility did not Provide documented evidence to show Resident 37 was repositioned every two hours during the night shift (10:30 PM to 6:30 AM) from 12/26/2024 to 1/24/2024. 2. Perform weekly skin assessments as indicated in Resident 37's care plan (CP), dated 1/2/2025, for two weeks. 3. Perform treatment for the unstageable PI (UPI, pressure…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the facility's policy titled Ordering and Receiving Non-Controlled Medications for two of two sampled residents (Resident 27 and 28) by failing to: a. Document the correct drug allergies into Resident 28's electronic medical record (EMR) when Resident 28 had 12 drug allergies and received Ambien (medication used to treat insomnia [difficulty in falling asleep]) nine times in 12/2024 which was indicated as one of the 12 drug allergies. b. Document the correct drug allergies in Resident 27's EMR when Resident 27's EMR did not indicate Resident 27 was allergic to clindamycin (type of antibiotic) and Norco (prescription medication used to treat moderate to severe pain) and incorrectly indicated an allergy to prednisone and prednisolone (medications used to treat swelling, redness, itching, and allergic reactions). These failures had the potential to result in Resident 27 and Resident 28 to sustain an adverse reaction to medications, such as, 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 follow the facility's infection prevention guidelines by failing to: A. Ensure enhanced barrier precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs, bacteria that have become resistant to certain antibiotics] in nursing homes) were followed during peri-care (washing the genitals [sexual organs located outside of the body] and anal [end of large intestine, allows feces to come out] area) in one of one sampled resident's room (Resident 4's room). B. Ensure a portable HEPA filtration system (filtration system designed to easily create a negative pressure isolation room) was in one of one sampled resident's room (Resident 190's room) per facility policy when Resident 190 tested positive for Coronavirus Disease (COVID-19, highly contagious and infectious disease that spread quickly door was observed to be opened through droplets released when an infected person coughs,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the facility's policy on Advance Directives (AD, legal document that indicates wishes for medical care if unable to speak for self) by failing to ensure one of one sampled resident's (Resident 27) code status was correct when Resident 27 had a Medical Doctor (MD) order for full code (when the resident's heart stops beating and/or the resident stops breathing, the resident or the resident's representative wish to perform all lifesaving procedures to keep the resident alive) and an emergency Medical Services Prehospital Do Not Resuscitate (DNR, medical order by MD to not provide cardiopulmonary resuscitation [CPR, an emergency lifesaving procedure, consisting of a combination of chest compressions, mouth-to-mouth, or mechanical breathing [a device used to help someone breathe]) Form (EMSPDNR). This failure had the potential to result in Resident 27 to receive incorrect emergency services. Findings During a review of Resident 27's admission…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and record review, the facility failed to ensure Registered Nurse 1 (RN 1) notified one of one sampled resident's (Resident 92) physician/medical doctor (MD 1) regarding Resident 92's increased agitation (unable to relax and be still) and confusion (unable to think clearly) when Resident 92 attempted to stand up unassisted from Resident 92's wheelchair (WC) multiple times on 1/20/2025 as indicated in the facility's policy and procedure (P&P) titled, Change in Resident Condition. This deficient practice had the potential to result in a physical decline to Resident 92. Cross Reference F744 Findings: During a review of Resident 92's admission Record (AR), the AR indicated Resident 92 was admitted to the facility on [DATE] with diagnosis that included Alzheimer's Disease (AD, a progressive and irreversible brain disorder that gradually destroys memory, thinking skills, and the ability to perform everyday tasks), and psychosis (a mental health condition characterized by a loss of contact 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 facility's Advance Beneficiary Notice of Non-coverage (SNFABN, a form that informs residents/responsible parties [RPs] Medicare may not cover certain items or services) form was signed for one of one sampled resident (Resident 26). This failure had the potential to result in the resident or the resident's RP to not make informed decisions regarding possible denied medical coverage. Findings: During a review of Resident 26's admission Record (AR), the AR indicated Resident 26 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia (impaired ability to remember, think, or make decisions that interfere with doing everyday tasks), hearing loss, and visual loss. During a review of Resident 26's History and Physical (H&P, formal document of a medical provider's examination of a patient) dated 10/21/2024, the H&P indicated Resident 26 did not have the capacity to understand and make…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 revise a care plan (CP) for two of two sampled residents (Resident 92 and Resident 5) when, A. Resident 92's CP for alteration in cognitive function related to Alzheimer's Disease (AD, a progressive and irreversible brain disorder that gradually destroys memory, thinking skills, and the ability to perform everyday tasks)/Dementia was not updated to include Resident 92's increased confusion on 1/20/2025. B. Resident 5's CP for depression was not updated to include use and current physician order for trazadone (medication used to treat depression [causes feelings of sadness and/or a loss of interest in activities]). These deficient practices had the potential to result in Residents 92 and 5 to not receive the necessary care and services in accordance with their specific needs. Findings: A. During a review of Resident 92's admission Record (AR), the AR indicated Resident 92 was admitted to the facility on [DATE] with diagnosis that included Alzheimer'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 record review, the facility failed to implement the facility's policy titled Oxygen Therapy by failing to: a. Connect Resident 12's Nasal Cannula (NC, medical device that provides oxygen through a tube and into the nose) tubing to the oxygen concentrator machine when Resident 12's NC was observed to be disconnected and on the floor. b. Label and date Resident 12's humidifier bottle when opened. These failures had the potential to result in complications associated with oxygen therapy for Resident 12. Findings: During a review of Resident 12's admission Record (AR), the AR indicated Resident 12 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic respiratory failure (damage to airways that limits the movement of oxygen), asthma (inflammation and tightening of muscles around the airways causing difficulty in breathing), and dependence of supplemental oxygen. During a review of Resident 12's Minimum Data Set (MDS, 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.

During an observation, interview, and record review, the facility failed to ensure a routine pain medication was available for one of one sampled resident (Resident 7). This deficient practice had the potential to result in pain and psychosocial decline to Resident 7. Findings: During a review of Resident 7's admission Record (AR), the AR indicated the facility admitted Resident 7 on 9/9/2017, with diagnoses that included unspecified fracture (broken bone) of the lower end of the left humerus (a long bone that runs from the shoulder and scapula [shoulder blade] to the elbow) with routine healing. During a review of Resident 7's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 10/27/2024, the MDS indicated Resident 7's cognition (ability to understand and process information) was intact. The MDS indicated Resident 7 had frequent pain and Resident 7 was on a scheduled pain medication regimen and was receiving prn (as needed) pain medication. During a review of Resident 7's Order Summary Report (OSR), dated active orders as of 1/24/2025. the OSR indicated an…

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

Based on interviews and record review, the facility failed to ensure psychotropic drugs (any medication capable of affecting the mind, emotions, and behavior) were not used unnecessarily for one of five sampled residents (Resident 32) by: 1. Ensuring that the use of Quetiapine (medication used alone or together with other medicines to treat bipolar disorder [depressive and manic episodes] and schizophrenia [a serious mental health condition that affects how people think, feel, and behave]) was clinically indicated and necessary for Resident 32. This deficient practice had the potential to result in use of unnecessary psychotropic drugs and could have led to side effects (injuries resulting from medication use including physical and mental harm, or loss of function) and adverse consequences to Resident 32. Findings: During a review of Resident 32's admission Record (AR), the AR indicated the facility admitted Resident 32 on 6/26/2024, and readmitted the resident on 10/30/2024, with diagnoses including hemiplegia/hemiparesis (paralysis [complete or partial loss of muscle function] on…

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

Based on observation, interview, and record review, the facility failed to ensure the dietary staff stored and prepared food under sanitary conditions in one of one kitchen (Kitchen 1). This deficient practice placed the residents at risk for foodborne illness (refers to illness caused by the ingestion of contaminated food or beverages). Findings: During an observation of Kitchen 1 on 1/21/2025 at 9:20 AM with the Sous-Chef (SC) (sous-chef-the second-in-command in a kitchen, responsible for helping the head chef run the kitchen smoothly) the following findings were observed: 1. Cook (CK) 1 was observed prepping rice with a ball cap (a soft hat with a rounded crown and a stiff front bill) and without a hairnet underneath the cap. 2. Four cottage cheese containers were stored in a walk-through refrigerator with a best if used by date of 12/29/2024. 3. One cake mix was stored in the dry foods area with a best if used by date of 1/10/2025. 4. Two dented cans of Marinara sauce were stored in the ready to use dry food area. Findings: During an interview on 1/21/2025 at 9:30 AM, with 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 the call light was within reach for one of one sampled resident (Resident 4). This deficient practice had the potential to result in a delay or the inability for Residents 4 to obtain necessary care and services. Findings: During a review of Resident 4's admission Record (AR), the AR indicated the facility admitted Resident 4 on 6/27/2019, and re-admitted the resident on 10/15/2024, with diagnosis including contracture (a permanent tightening of muscles, tendons, ligaments, or skin that limits movement in a joint) of muscle, hemiplegia/hemiparesis (paralysis [complete or partial loss of muscle function] on one side of the body), and hemiparesis, and age-related osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D). During a review of Resident 4's History and Physical (H&P), dated 9/23/2024, the H&P indicated Resident 4 could make needs known but could not make medical decisions. During a review of Resident 4's Minimum Data Set (MDS, a federally mandated resident 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.

Based on interview and record review, the facility failed to report an allegation of physical abuse to the state agency (California Department of Public Health, CDPH) and law enforcement no later than two hours for one of seven sampled residents (Resident 2) and indicated in the facility's abuse prevention policy and procedure (P&P), titled, Adult Abuse,. This deficient practice resulted in the delay of notification to the state agency and had the potential for the residents residing at the facility to be subjected to further abuse. Cross Reference F610 Findings: During a review of Resident 2's admission Record (AR), the AR indicated the facility originally admitted Resident 2 on 6/9/23 and readmitted Resident 2 on 6/16/23 with diagnoses including encephalopathy (a group of conditions that cause brain dysfunction), muscle weakness (a lack of muscle strength), hypertensive heart disease (long standing elevated blood pressure), and acute diastolic heart failure (a sudden serious condition that occurs when the heart can't pump enough blood to meet the body's needs). During a review of…

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

Based on interview and record review, the facility failed to immediately remove a potential threat for one of seven sampled residents (Resident 2). On 9/13/24, the facility received a report that indicated Certified Nursing Assistant 1 (CNA 1) squeezed Resident 2's brief around his genitalia (male or female reproductive organs) area to check if Resident 2's brief was wet. The facility failed to remove (CNA 1) from resident care duties and failed to make every attempt to prevent further potential abuse while the facility's investigation was in progress as indicated in the facility's abuse prevention policy and procedure (P&P), titled, Adult Abuse,. This deficient practice had the potential to result in further abuse for Resident 1 and for the residents residing at the facility. Cross Reference F609 Findings: During a review of Resident 2's admission Record (AR), the AR indicated the facility originally admitted Resident 2 on 6/9/23 and readmitted Resident 2 on 6/16/23 with diagnoses including encephalopathy (a group of conditions that cause brain dysfunction), muscle weakness (a lack…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and record review, the facility failed to report an alleged verbal abuse of one of three sampled residents (Resident 2) by Resident 3 within the required time frame to the State Survey Agency (SSA), Long-Term Ombudsman (LTO), and the local law enforcement (LLE). This failure had the potential to result in further abuse of Resident 2 and/or other residents related to the delayed investigation of alleged abuse and the necessary interventions to prevent abuse. Findings: 1a. During a review of Resident 2's Face Sheet (FS 1, admission record), FS 1 indicated the facility admitted Resident 2 on 11/10/2023, with multiple diagnoses including hypertensive heart disease (HHD, abnormal changes in the heart due to long-standing high pressure of the blood against the walls of the arteries), abnormalities of gait, and unsteadiness on feet. During a review of Resident 2's Minimum Data Set (MDS 1, a standardized resident assessment and care-planning tool), dated 2/16/2024, MDS 1 indicated Resident 2 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.

Based on observation, interview, and record review, the facility failed to follow infection control practices during a Coronavirus (COVID-19, a mild to severe respiratory illness that spread from person to person) outbreak (a sudden increase in occurrences of a disease when cases are in excess of normal expectancy for the location or season) in accordance with the Department of Public Health's (DPH) guidelines and the facility's Policy and Procedure (P&P) by failing to: 1. Conduct annual N95 mask (respirator, a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) fit testing (the use of a protocol to evaluate the fit of a respirator on an individual) for one (1) of four (4) sampled staff members 2. Notify all residents and family representatives about the facility's COVID-19 outbreak in a timely manner. These deficient practices had the potential to result in the spread of COVID-19 throughout the facility and the community and the potential to compromise the health of the residents, staff, and visitors.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the dignity of two of two sampled residents (Residents 14 and 17): a. For Resident 14, facility staff failed to promptly respond to Residents 14's call light (a device used by a resident to signal his or her need for assistance from staff). Resident 14 felt rushed when staff provided care for Resident 14. b. For Resident 17, facility staff failed to promptly respond to Resident 17's call light during the night shift. These failures resulted with feeling frustration to Residents 14 and Resident 17 to felt like Resident 17 wanted to die. The failures had the potential to result in both residents to feel like their concerns were unheard and disrespected. Findings: a. During a review of Resident 14's Face Sheet (FS, admission Record), the FS indicated Resident 14 was admitted to the facility on [DATE] with multiple diagnoses including Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide the necessary care and services for two of two sampled residents (Resident 35 and Resident 37) by failing to ensure: a.A physician's order, that indicated continuous oxygen (O2, gas that the body needs to live) administration through a nasal cannula (NC, a device that gives you additional oxygen through your nose) two liters (L, measurement of volume) per minute (2L/min), was followed for Resident 35. On 1/8/24, Resident 35's NC was attached to an empty O2 tank. b.For Resident 37, the facility failed to conduct a comprehensive weekly assessment and take vital signs monthly as indicated in the facility's policy and procedure titled, Assessment, Licensed Weekly Summary, and Vital Signs, Monitoring of. These failures had the potential to result in Resident 35 to experience shortness of breath and had the potential to result in a delay in treatment, a decline in physical, and overall wellbeing for Residents 35 and 37. Findings: During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure assistive hearing devices were available to maintain hearing for two of two sampled residents (Residents 34 and Resident 35). a. Resident 34 was hard of hearing (HOH) and was not provided with hearing aids during activities as indicated in the care plan, titled, Communication, Alteration in related to Hard of Hearing. b. Resident 35 was HOH and was not provided with audiology services to address Resident 35's hearing impairment nor provided with hearing aids. These failures resulted in Resident 34 looking frustrated, not being able to hear, and unable to participate in activities. The failures had the potential to result in further hearing loss and impact Residents 34 and Resident 35's psychosocial wellbeing. Findings: a. During a review of Resident 34's Face Sheet (FS, admission record) the FS indicated, Resident 34 was admitted to the facility on [DATE] with multiple diagnoses including muscle weakness (generalized), lumbago with…

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

Based on observation, interview, and record review, the facility failed to follow safe food handling practices in accordance with the facility's policy and procedures (P&P), by: a. Failing to label, and date opened food items stored in a refrigerator located in one of two kitchens (Main Kitchen). b.Failing to maintain one of one refrigerator's, in the Service Kitchen located by the Dining Room, temperature at or below 41 degrees F (Fahrenheit, a unit of measurement). These deficient practices had the potential to result in serious complications from food borne illness (illness caused by the ingestion of contaminated food or beverage) due to expired or potentially expired foods for all residents residing at the facility and who consumed meals by mouth. Findings: During a concurrent observation and interview on 1/8/24 at 10:30 a.m. with the Executive Chef (EF) during the initial brief tour of the Main Kitchen located in the Building 1, the following were observed: 1. a loaf of 18 count Lemon Glazed Pullman bread was out on a cart and the loaf of bread was not labeled with an opened 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 observation, interview and record review, the facility failed to follow standard infection control practices for two of two sampled residents (Resident 96 and Resident 146) in accordance with the facility 's policy and procedures (P&P) by failing to: a.Ensure Resident 96's nasal cannula (NC, is a device to deliver oxygen or increased airflow to a person in need of respiratory help) was not touching the floor. b.Ensure Resident 146's dentures were labeled and stored properly when not in use. These failures had the potential to result in infections and physical declines to Residents 96 and 146. Findings: a.During a review of the Face Sheet Face Sheet (FS, admission record) the FS indicated Resident 96 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure (when lungs cannot get enough oxygen to the heart), pulmonary hypertension (high blood pressure that effects the lungs and heart) and hypertension (elevated blood pressure). During a review of Resident 96'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 record review, the facility failed to provide Resident 22 appropriate accommodations when Resident 22's call light cord was not with-in reach. This failure had the potential to result in delayed care and treatment to Resident 22 and Resident 22's needs not being met. Findings: During an observation, on 1/8/24 at 11:44 am, Resident 22 was observed sitting on a wheelchair positioned by the foot of the bed and Resident 22 was approximately 3 feet away from the bed. Resident 22's call light cord was observed on the middle of the Resident 22's bed and not within the resident's reach. During a review Resident 22's Face Sheet (FS, admission record), the FS indicated Resident 22 was re-admitted to the facility on [DATE] with diagnosis that included history of falling, Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors on hands), and repeated falls. During a review of Resident 22's History and Physical (H&P), dated 12/18/23, 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 transmit a Minimum Data Set (MDS) within 14 days after a resident's Discharge Assessment was completed for one of one sampled resident (Resident 7). This failure had the potential to result in an inaccurate assessment of the facility's quality indicators and/or care area concerns for review. Findings: During a review of Resident 7's Face Sheet (FS, admission Record), the FS indicated Resident 7 was admitted to the facility on [DATE] with multiple diagnoses including unspecified fracture (broken bone) of T5-T8 (bones of the spine [backbone]) and history of falling. The FS indicated Resident 7 was discharged from the facility on 9/10/2023. During an interview on 1/11/24 at 1:56 p.m. with the MDS Nurse (MDSN), the MDSN stated Resident 7 was discharged from the facility on 9/10/23. The MDSN stated the Discharge Assessment had not been submitted to CMS (Centers for Medicare and Medicaid Services) since Resident 7 was discharged from the facility. The MDSN…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 revise the comprehensive care plan for falls for one of one sampled resident (Resident 14), as indicated in the facility's policy and procedure (P&P), titled, Fall Prevention and Management. Resident 14's care plan for falls was not updated to include additional or different interventions following Resident 14's fall at the facility on 10/10/2023. This failure had the potential for Resident 14 to not receive appropriate care and interventions to prevent further incidents of falls. (Cross reference F689) Findings: During a review of Resident 14's Face Sheet (FS, admission Record), the FS indicated Resident 14 was admitted to the facility on [DATE] with multiple diagnoses including Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) and muscle weakness. During a review of Resident 14's Minimum Data Set (MDS, a standardized assessment and care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 assessments were completed every shift/daily to prevent pressure injuries (PI, pressure ulcer, injury to skin and underlying tissue resulting from prolonged pressure on the skin and/or underlying soft tissue usually present over a bony prominence) for one of one sampled resident (Resident 147) as indicated by Resident 147's care plan titled, Risk for Skin Breakdown, and the facility's policy and procedure (P&P) titled, Assessment, Body. This deficient practice resulted in a facility acquired Stage 3 (the ulcer/injury has gone through all layers of skin into the fat tissue, exposing the patient to infection) PI on Resident 147's coccyx (tailbone) area on 1/3/24. Findings: During a review of Resident 147's Face Sheet (FS, admission record) the FS indicated, Resident 147 was admitted to the facility on [DATE] with multiple diagnoses including unsteadiness on feet, other abnormalities of gait (walk) and unspecified atrial fibrillation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interdisciplinary team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of the resident) failed to assess a resident's fall risk and reassess fall prevention interventions for one of one sampled resident (Resident 14), as indicated in the facility's policies and procedures (P&P), titled, Fall Prevention and Management Program. This failure had the potential to result in Resident 14 to sustain an injury and/or harm due to additional falls. (Cross reference F657) Findings: During a review of Resident 14's Face Sheet (FS, admission Record), the FS indicated Resident 14 was admitted to the facility on [DATE] with multiple diagnoses including Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) and muscle weakness. During a review of Resident 14's Minimum Data Set (MDS, a standardized assessment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 enteral feeding ([also referred to as tube feeding] the delivery of nutrients through a feeding tube directly into the stomach, duodenum, or jejunum) syringe was replaced after 24 hours for one of two sampled residents (Residents 5). This failure had the potential to result in Resident 5 to develop an infection and complications including but not limited to diarrhea and vomiting. Findings: During a review of Resident 5's Face Sheet (FS) the FS indicated, Resident 5 was originally admitted to the facility on [DATE] and last readmitted on [DATE] with multiple diagnoses including contracture (occurs when your muscles, tendons, joints, or other tissues tighten or shorten causing a deformity) of muscle, dysphagia (difficulty swallowing) and type 2 diabetes mellitus (adult onset disease characterized by high levels of sugar in the blood). During a review of Resident 5's Physician's Order (PO), dated 12/11/23, the PO indicated,…

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

Based on interview and record review, the facility failed to ensure the facility had a Registered Nurse (RN) at least 8 consecutive hours a day for 7 days a week for three out of 42 days reviewed for staffing assignments. This failure had the potential to result in a decline in residents' physical and/or psychosocial wellbeing due to insufficient monitoring, and coordination of care and services by an RN. Findings: During a concurrent interview and record review on 1/10/24 at 2 p.m. with the Director of Staff Development (DSD), the facility's, Daily Assignments, and Nursing Staffing Assignment and Sign-in Sheets (CDPH 530) were reviewed: The Daily Assignments, dated 8/13/23 indicated a RN was scheduled to work that day. The CDPH 530 dated 8/13/23, was not signed by the RN scheduled to work that day. The DSD stated the RN would have signed on the CDPH 530 if the RN worked. The DSD stated the facility did not have RN coverage on 8/13/23. The Daily Assignments, dated 9/24/23 indicated a RN was scheduled to work that day. The CDPH 530 dated 9/24/23, was not signed by the RN scheduled 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 interview and record review, the facility failed to ensure, for one of one Daily Nurse Staffing Form, and post actual worked nursing hours at the start of each shift. This failure resulted in inaccurate nursing staff hours worked, the failure had the potential to result in residents and family members obtaining misleading information from the posted form that indicated projected hours and not actual hours worked. Findings: During an interview on 1/10/24 at 4 p.m. with the Administrator (ADM), The ADM stated the facility did not have a Policy and Procedure (P&P) for posting the facility's nurse staffing data. During an interview on 1/11/24 at 1:24 p.m. with the Director of Staff Development (DSD), The DSD stated the DSD posted the Daily Nurse Staffing Form on the unit daily in the morning. The DSD stated the DSD would post the Daily Nurse Staffing Form for Saturday and Sunday on Friday before the DSD left at the end of the day. The DSD stated the Daily Nurse Staffing Form only indicated the projected staffing hours for each shift and not the actual hours worked by the staff.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 infection control practices during a Coronavirus (COVID-19, a mild to severe respiratory illness that spread from person to person) outbreak (a sudden increase in occurrences of a disease when cases are in excess of normal expectancy for the location or season) in accordance with the Department of Public Health's (DPH) guidelines and the facility's Policy and Procedure (P&P) by failing to annually conduct N95 mask (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) fit testing (the use of a protocol to evaluate the fit of a respirator on an individual) for sixty three (63) of sixty eight (68) staff members. This deficient practice had the potential to result in the spread of COVID-19 throughout the facility and the potential to compromise the health of the residents, staff, and visitors. Findings: During an interview on [DATE] at 10:29 a.m. with the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure all treatments and services were provided to one of three sampled residents (Resident 1) by failing to follow Resident 1's physician's order to obtain a neurology consult (a medical doctor who specializes, diagnoses, treats and manages disorders of the brain and nervous system [brain, spinal cord and nerves]). This deficient practice resulted in Resident 1 not being seen and evaluated by an neurologist and had the potential to cause a negative impact on Resident 1's well-being. Findings: During a review of Resident 1's Face Sheet indicated, Resident 1 was originally admitted on [DATE] and readmitted on [DATE] with multiple diagnoses including myelodysplastic syndrome (a group of disorders caused by blood cells that are poorly formed or don't work properly) and asthma (a chronic [long-term] condition that affects the airways in the lungs). During a review of Resident 1's History and Physical Examination (H&P) dated 3/10/23,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, for one of two sampled residents (Resident 1), adequate monitoring and supervision for Resident 1 who was at risk for elopement. On 8/4/2023, Resident 1 was found sitting on Resident 1's wheelchair located outside of the facility and on the facility driveway. This failure resulted in compromised safety to Resident 1 and had the potential to result in life-threatening injuries and/or death to Resident 1. Findings: A review of Resident 1's Face Sheet (AR, admission Record), the AR indicated, Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of history of falling. A review of Resident 1's Physician Visit Note (PVN), dated 10/24/2022, indicated, Resident 1 was admitted with multiple diagnoses including heart disease, hypertension (high blood pressure) and dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough 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 follow infection control and prevention practices in accordance with the local Department of Public Health's (DPH) guidelines and the facility's Policy and Procedures (P&P) to prevent and control the spread of COVID-19 (Coronavirus, an infectious disease that can cause mild to severe respiratory illness and is a virus that spreads from person to person) when one of two staff (Mobile Phlebotomist [MP] failed to remove (doff) PPE (personal protective equipment, protective clothing, helmets, goggles, or other garments or equipment designed to protect the wearer's body from injury or infection) prior to exiting Room A located in the red zone (a cohort or group of residents who are positive for COVID-19). This failure had the potential to result in the spread of COVID-19, severe respiratory illness, hospitalization, and/or death amongst the facility's residents and healthcare staff. Findings: During an observation on 8/21/2023, at 12:20 p.m., Rooms A and B had signages posted outside of the room and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to hold glipizide (a medication used to lower sugar in the blood) when the resident's blood sugar was less than 100 milligrams per deciliter (mg/dL, concentration of sugar in person's blood) for seven of seven dates (from 8/1/23 to 8/7/23) per the Physician's Order for one of one sampled resident (Resident 1). Glipizide was administered to Resident 1 when the resident's blood sugar level was less than 100 mg/dL. This deficient practice had the potential to place the Resident 1 at risk for hypoglycemic (low blood sugar that can cause confusion) episode and cause unnecessary harm. Findings: During a review of Resident 1's Face Sheet (admission Record), the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnosis that included generalized muscle weakness, Type 2 diabetes mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) and abnormality of gait. During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to treat one of one sampled resident (Resident 1) with respect and dignity while providing care. On 8/7/23, Certified Nurse Assistant 1 (CNA 1) did not stop turning Resident 1 when Resident 1 asked CNA 1 to stop. This failure resulted in Resident 1 feeling bad and had the potential to affect Resident 1's psychosocial well-being. Findings: During a review of a face sheet (admission record) indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included generalized muscle weakness and abnormality of gait (walk). During a review of a Minimum Data Set (MDS, a resident assessment and care-screening tool), dated 7/13/23, indicated Resident 1 had clear speech, had the ability to understand (clear comprehension), and made herself understood. The MDS indicated Resident 1 required extensive assistance from one person for bed mobility (how resident moved to and from laying position, turns side to side and positions body while in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an allegation of financial abuse for one of three sample resident (Resident 1) to the California Department of Public Health (CDPH, the Department), Ombudsman (an official appointed to investigate individuals' complaints against maladministration), and to the local law enforcement, within 2 hours, according to the facility's Policy and Procedure (P&P). This failure resulted in untimely reporting and had the potential to result in Resident 1's money to be stolen or misused. Cross reference F943 Findings: During a review of Resident 1's Face Sheet, updated 6/5/23, the Face Sheet indicated, Resident 1 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with multiple diagnoses including spinal stenosis (a narrowing of the spinal canal), pain in the right shoulder, and presence of cardiac pacemaker(medical device which sends electrical pulses to help your heart beat at a normal rate and rhythm). During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure proper training on how to identify an allegation of financial abuse for three of five sampled facility staff (Licensed Vocational Nurse 1 [LVN 1], the Director of Nursing [the DON], and Certified Nursing Assistant 1 [CNA 1]). LVN 1, the DON, and CNA 1 failed to identify Resident 1's claim of missing money as an allegation of financial abuse. This failure had the potential to result in Resident 1's money to be stolen or misused. Cross reference F609 Findings: During a review of Resident 1's Face Sheet, updated 6/5/23, the Face Sheet indicated, Resident 1 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with multiple diagnoses including pain in the right shoulder, and presence of cardiac pacemaker (medical device which sends electrical pulses to help your heartbeat at a normal rate and rhythm). During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 5/31/23,…

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