Covina Rehabilitation Center

Based on observation, interview, and record review, the facility failed to ensure Restorative Nursing Assistant 1 (RNA 1) (RNA, a Certified Nursing Assistant who is trained to assist residents with restorative care such as exercises, walking, and restorative equipment) was competent in providing RNA services to one of seven sampled residents (Resident 7) for splinting (applying and/or removing splint(s) [device used to immobilize a body part]) when RNA 1 did not apply Resident 7's custom right-hand splint as ordered by the physician. This deficient practice had the potential to cause Resident 7 and other residents receiving RNA services in the facility to experience pain, injury, and skin breakdown (tissue damage caused by friction, shear, moisture, or pressure). During a review of Resident 7's Face Sheet (FS, document that contains a patient's personal and contact information, diagnoses, and medical history), the FS indicated the facility initially admitted Resident 7 to the facility on 7/11/2024 and readmitted Resident 7 on 3/12/2026 with diagnoses which included myelin…

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

Based on interview and record review, the facility failed to provide sufficient number of nursing staff according to the facility's policy and procedure (P&P) titled, Staffing, Sufficient and Competent, and Facility Assessment Tool (FA Tool), by failing to: 1. Ensure certified nursing assistants (CNA) were not assigned more than 12 residents on 5/6/2025, 5/7/2025, 5/14/2025, 5/15/2025, and 5/18/2025 on the 11 pm to 7 am (noc) shift on Station 3. 2. Ensure there were seven assigned CNAs on the 7 am to 3 pm (morning) shift in Station 3 on 5/26/2025. As a result of these failures, on 5/6/2025, 5/7/2025, 5/14/2025, 5/15/2025, and 5/18/2025 CNAs working in Station 3 were assigned between 24 and 25 residents during the noc shift. On 5/26/2025, there were five CNAs working in Station 3 during the AM shift. Resident 1 had a fall (move downward, typically rapidly and freely without control, from a higher to a lower level) while being transferred (moving a resident from one place to another) in a Hoyer lift (mechanical lift- a device used by staff to transfer residents from one location to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure nursing staff had the appropriate skills and competency necessary to provide nursing care and services to one of four sampled residents (Resident 1), according to the facility's policy and procedure (P&P) titled, Staffing, Sufficient and Competent Staffing, and the Inservice on the use of Hoyer lift (mechanical [made or operated by a machine] lift - a device used by staff to lift and transfer residents from bed to a chair or one location to another), dated 2/19/2025 by failing to: Ensure Certified Nursing Assistant (CNA) 4 provided two-person physical assistance (help from two persons) to transfer (moving a resident from one place to another) Resident 1 from Resident 1's bed to the shower gurney (mobile bed used to assist in bathing residents) when CNA 4 used the Hoyer lift. As a result of this failure, on 5/26/2025 at 9:45 am, Resident 1 fell (move downward, typically rapidly and freely without control, from a higher to a lower level) to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the pad sensor/call lights were within reach for three of three sampled residents (Residents 9, 14, and 34). These failures had the potential for the residents not to receive or receive delayed care that could result in a fall or accident. Findings: a. During a review of Resident 9's admission Record (AR), the AR indicated Resident 9 was admitted to the facility on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities), osteoporosis (weak and brittle bone due to lack of calcium and vitamin D) and traumatic fracture (a bone break caused by a sudden, strong force, like a fall or car accident). During a review of Resident 9's untitled Care Plan (CP) dated 6/14/2024, the CP indicated Resident 9 was at risk for falls/injury related to impaired mobility, use of psychotropic medications and unsteady gait. The CP interventions included staff to keep the resident's call light within easy reach and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two of three sampled residents' (Resident 16 and 23's) swallowing/nutritional status was accurately assessed and coded in Resident 16 and 23's Minimum Data Set (MDS- a resident assessment tool). This deficient practice resulted in inaccurate reporting to the Centers for Medicare and Medicaid Services (CMS, a federal agency that administers major healthcare programs in the United States) and had the potential for Residents 16 and 23 to not receive interventions to address specific care concerns. Findings: a. During a review of Resident 23's admission Record (AR), the AR indicated Resident 23 was admitted to the facility on [DATE], with diagnoses that included Alzheimer's disease (a disease characterized by a progressive decline in mental abilities) and convulsions (rapid, involuntary muscle contractions that cause uncontrollable shaking and limb movement). During a review of Resident 23's MDS, dated [DATE], the MDS indicated Resident 23 had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to change the dressing (a clean or sterile covering) every seven (7) days for two of two sampled residents' (Resident 63's and 294's) central line (a flexible tube inserted into a vein in the neck, chest, arm or groin) and midline intravenous (IV- existing or taking place within a vein/s) catheter (a long, thin, flexible tube that is inserted in the upper arm with the tip located just below the axilla [armpit]) in accordance with Resident 63's and Resident 294's care plan and the facility's policies and procedures (P&P) titled, Midline Catheter Dressing Change, and Peripheral and Midline IV Dressing Changes. This failure had the potential to result in an infection for Resident 63 and 294 and worsen Resident 63's and 294's health condition. Findings: a. During a review of Resident 294's admission Record (AR), the AR indicated Resident 294 was admitted to the facility on [DATE], with diagnoses that included other acute osteomyelitis (infection…

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

The facility failed to provide a 24-hour sufficient nursing staffing on one of fourteen Saturdays and one of fourteen Sundays for Quarter 1 of 2024 (10/1/2024 to 12/31/2024) consistent with Payroll Based Journal (PBJ, a system for collecting and reporting staffing information from nursing homes and other long-term care facilities) Staffing Data Report. The facility did not meet the required 2.4 Certified Nursing Assistant (CNA) direct care hours per patient day on 12/1/2024 and 12/14/2024. These failures had the potential to affect the quality of care and negatively affect the resident's quality of life in the facility. Findings: During a review of the facility's PBJ Staffing Data Report for Quarter 1 for 2024, from 10/1/2024 to 12/31/2024, the PBJ staffing Data Report indicated the facility had an excessively low weekend staffing. During a concurrent interview and record review on 4/18/2025 at 2:18 pm with the Director of Staff Development (DSD), the Weekend Nursing Staffing Assignment and Sign in Sheet from 10/1/2024 to 12/31/2024, the weekend Direct Care Service Hours Per Patient…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two of three sampled residents (Residents 35 and 89) were not administered Epoetin Alfa-epbx (Epogen, a medication to treat anemia [a condition when the blood does not have enough red blood cells or reduced amount of hemoglobin [Hgb, a protein in red blood cells that carries oxygen throughout the body]) injections as indicated in Residents 35 and 89's physicians orders (PO) to hold Epogen injections when Residents 35 and 89's Hgb level was > (more than) 10 grams per deciliter (g/dl, unit of measurement for Hgb). As a result, Resident 35 received 19 unnecessary (extra/not needed) doses of Epogen injections from [DATE] to [DATE] ([DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]) when Resident 35's Hgb level was at 11.5 g/dl. Resident 89 received three unnecessary doses of Epogen injections from [DATE] to [DATE] ([DATE], [DATE] and [DATE]) when…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safe and sanitary environment to help prevent the development and transmission of communicable diseases for three of five sampled residents (Residents 5, 24, and 1) by failing to: a. Ensure staff implemented the facility's Policy and Procedure (P&P) titled, Enhanced Barrier Precaution (EBP, precautions that include the use of a gown and gloves during high contact resident care activities for residents), to prevent the spread of infections for Residents 5 and 24. b. Ensure Resident 1's oxygen tubing was not on the floor. These failures had the potential to result in transmission of multidrug-resistant organisms (MDRO, bacteria that is resistant to antibiotics (medicine used to stop or kill the growth of bacteria) to other residents in the facility. Findings: a1. During a review of Resident 5's admission Records (AR), the AR indicated Resident 5 was initially admitted to the facility on [DATE], and readmitted on [DATE], with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide privacy for one of 22 sampled residents (Resident 69) when staff did not close the privacy curtain while checking Resident 69's Gastrostomy tube (G-tube, feeding tube that is surgically placed through an opening into the stomach from the abdominal wall) site. This deficient practice violated Resident 69's right to bodily privacy and resulted in unnecessary exposure of Resident 69's abdominal area and lower extremities. This deficient practice had the potential to affect Resident 69's psychosocial (mental and emotional) well-being, self-esteem, and self-worth. Findings: During a review of Resident 69's admission Record (AR), the AR indicated Resident 69 was admitted to the facility on [DATE], with diagnoses that included encounter for attention to gastrostomy (creation of an artificial external opening into the stomach for nutritional support) and dysphagia (difficulty swallowing). During a review of Resident 69's Care Plan (CP)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 complete a discharge assessment Minimum Data Set (MDS, a standard resident assessment and care screening tool) per Center of Medicare & Medicaid Service (CMS- a federal agency that provides health coverage and focuses on improving the quality and outcome within the healthcare system) requirement for one of one sampled resident (Resident 82). This failure had the potential for inaccurate reporting to CMS and for Resident 82 not to receive necessary care and services. Findings: During a review of Resident 82's admission Record (AR), the AR indicated Resident 82 was admitted to the facility on [DATE] with diagnoses including difficulty in walking and hypertension (high blood pressure). During a review of Resident 82's Minimum Data Set (MDS, a resident assessment tool) dated 12/11/2024, the MDS indicated Resident 89 had clear speech, had the ability to understand others and make self-understood. Resident 82 required partial/moderate assistance (helper does…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an individualized and comprehensive communication plan of care for one of one sampled resident (Resident 50) with language barrier. This failure resulted in Resident 50 not receiving individualized care and did not maintain the resident's highest physical and mental well-being. Findings: During a review of Resident 50's admission Record (AR), the AR indicated Resident 50 was readmitted to the facility on [DATE] with diagnoses that included chronic kidney disease (longstanding disease of the kidneys), Type 2 diabetes mellitus (body has trouble controlling and using blood sugar) and essential hypertension (high blood pressure with no known underlying cause). During a review of Resident 50's History & Physical (H&P) dated 2/24/25, the H&P indicated Resident 50 did not have the capacity to make medical decisions. During a review of Resident 50's Minimum Data Set (MDS, a resident assessment tool) dated 2/27/25, the MDS 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 observation, interview, and record review, the facility failed to maintain the bed alarm in proper working and functional condition for one of three sampled residents (Resident 34) reviewed for accidents and hazards. This failure placed Resident 34 at risk for a preventable fall/accident. Findings: During a review of Resident 34's AR, the AR indicated Resident 34 was readmitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy (disease that affects the function or structure of the brain), Parkinson's disease (disease that affects the nerve cells in the brain that produces symptoms that include muscle rigidity, tremors, and changes in speech and gait) and muscle weakness (decreased strength in muscles). During a review of Resident 34's History & Physical (H&P) dated 10/27/24, the H&P indicated Resident 34 had the capacity to make decisions for activities of daily living (ADLs- basic self-care tasks). During a review of Resident 34's Minimum Data Set (MDS, a resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) to change the face mask (an oxygen delivery device) for breathing treatment every seven days for one of three sampled residents (Resident 35). This failure had the potential to result in infection for Resident 35. Findings: During a review of Resident 35's admission Record (AR), the AR indicated Resident 35 was readmitted to the facility on [DATE] with diagnoses including End Stage Renal Disease (ESRD, irreversible kidney failure), dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 35's Minimum Data Set (MDS, a resident assessment tool) dated 3/10/2025, the MDS indicated Resident 35 had clear speech, had the ability to understand others and made self-understood. The MDS indicated Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement its policy and procedure (P&P) titled, Bed Safety and Bed Rails, for one of one sampled resident (Resident 5) when staff did not attempt alternative interventions prior to the use of bed rails and did not obtain informed consent for the use of bed rails for Resident 5. These failures placed Resident 5 at risk for entrapment (an event in which resident was caught, trapped, or entangled in a tight space around the bed) and injury from the use of side rails and to be uninformed about the risks and benefits of side rails. Findings: During a review of Resident 5's admission Records (AR), the AR indicated Resident 5 was initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included respiratory failure (occurs when the lungs could not properly exchange gases, causing abnormal levels of carbon dioxide and/or oxygen in the arteries), dementia (a progressive state of decline in mental abilities), and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure complete and accurate documentation for one of one sampled resident (Resident 37) on a Low Air loss Mattress (LAL- a medical mattress designed to prevent and treat pressure wounds) when Resident 37's use and monitoring of LAL was not documented in Resident 37's Treatment Administration Record (TAR). This failure resulted in Resident 37's medical record to contain incomplete information and had the potential to affect Resident 37's care. Findings: During a review of Resident 37's admission Record (AR), the AR indicated Resident 37 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing) and peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs). During a review of Resident 37's Physician Order (PO), dated 1/8/2025, the PO indicated Resident 37 had an order for LAL for wound care and…

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

Based on interview and record review, the facility failed to revise a care plan (CP) for one of three sampled residents (Resident 1) when Licensed Vocation Nurse 1 (LVN 1) failed to provide safe seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) management for Resident 1 while Resident 1 experienced a seizure on 10/9/2024 as indicated in Resident 1's CP titled, Seizure Disorder and the facility's policies and procedures (P&P) titled, Emergency Procedure -Seizure Management and Care Plans, Comprehensive Person-Centered. This failure had the potential to result in inconsistent provision of treatments and services, unmet individualized needs for Resident 1, and the potential to affect Resident 1's physical and psychosocial well-being. Cross Reference F684 Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility originally admitted Resident 1 on 04/22/2022 and readmitted Resident 1 on 06/30/2024, with diagnoses that included respiratory failure (a serious…

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

Based on interview and record review, the facility failed to provide safe seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) management for one of three sampled residents (Resident 1) as indicated in the facility's policy and procedure (P&P) titled, Emergency Procedure -Seizure Management and Resident 1's CP titled, Seizure Disorder. On 10/9/2024 Resident 1 experienced a seizure and Licensed Vocation Nurse (LVN 1) wrapped a tongue depressor and inserted the tongue depressor in Resident 1's mouth. This failure had the potential to result in chocking to Resident 1 and the potential to result in a decline in Resident 1's physical well-being. Cross Reference F657 Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility originally admitted Resident 1 on 04/22/2022 and readmitted Resident 1 on 06/30/2024, with diagnoses that included respiratory failure (a serious condition that happens when your lungs cannot get enough oxygen into your blood or remove…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 readmit one of one sampled resident (Resident 1) from General Acute Care Hospital (GACH) 1 after Resident 1 was cleared by GACH 1 to return to the facility on [DATE]. This deficient practice had the potential to result in the denial of Resident 1's rights to return to the facility. Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to facility on 9/5/2024, with diagnoses including respiratory failure (when the lungs cannot get enough oxygen into the blood), quadriplegia (the condition in which both the arms and legs are paralyzed [unable to move]), and type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar). During a review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 9/25/2024, the MDS indicated the resident had severely impaired (never/rarely made decisions) cognitive skills (ability to make daily…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received his pain medication as ordered by the physician. This failure resulted in Resident 1 to feel mad and had the potential for Resident 1 to experience unrelieved pain. Cross Reference F755 Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including respiratory failure (when the lungs cannot get enough oxygen into the blood), difficulty in walking, and dysphagia (difficulty swallowing foods or liquids). During a review of Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 7/1/2024, the MDS indicated Resident 1 had no impairment in cognitive skills (ability to make daily decisions). Resident 1 was dependent (helper does all the effort) on staff for toileting and bathing. The MDS indicated Resident 1 did not have pain in the last five days. 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 ensure the supply of pain medication for one of three sampled residents (Resident 1) was refilled/restocked timely (promptly/without delay) and readily available when Resident 1 needed the medication. This failure resulted in Resident 1 to feel mad and had the potential for Resident 1 to experience unrelieved pain. Cross Reference F697 Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to facility on 6/25/2024 with diagnoses including respiratory failure (when the lungs cannot get enough oxygen into the blood), difficulty in walking, and dysphagia (difficulty swallowing foods or liquids). During a review of Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 7/1/2024, the MDS indicated Resident 1 had no impairment in cognitive skills (ability to make daily decisions). Resident 1 was dependent (helper does all the effort) on staff for toileting and bathing. The MDS indicated Resident 1 did not have pain in the last five days. During…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure three of five sampled residents (Residents 4, 5, and 6) had a comfortable and homelike environment for three days when the facility failed to ensure the air temperatures were safe and comfortable in nine of 20 resident rooms, according to the facility's policy and procedure (P&P) titled, Homelike Environment, revised February 2021. This failure resulted in Residents 4, 5, and 6 being uncomfortable and had the potential to negatively affect residents' (in general) health and well-being. Findings: a. During a review of Resident 4's admission Record (AR) the admission record indicated Resident 4 was admitted to the facility on [DATE] with diagnoses that included multiple sclerosis (MS, a chronic disease that affects the brain and spinal cord), quadriplegia (the condition in which both the arms and legs are paralyzed), and congestive heart failure (condition in which the heart cannot pump enough blood to all parts of the body). During…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 promptly (quickly/timely) notify the physician for two of six sampled residents (Resident 2 and Resident 3) who experienced a change of condition (COC- a sudden clinically important deviation from a resident/patient's baseline in physical, behavioral, or functional domains) as indicated in Resident 2's untitled care plan (CP) for fall risk, Resident 3's untitled CP for urinary catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag), and the facility's policies and procedures (P&P) titled, Change in a Resident's Condition or Status, by failing to: 1. Ensure Registered Nurse (RN) 3 and Licensed Vocational Nurse (LVN) 7 notified Resident 3's primary physician/medical doctor (MD) when Resident 3 was noted with bleeding and blood clots (gel-like clumps of blood) after the removal of Resident 3's urinary catheter 2 on 6/18/2024 at 3 pm. 2. Ensure RN 4 and LVN 8 notified Resident 2's Medical Doctor/Primary Physician (MD) 1 on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement the care plans (CP) for one of six sampled residents (Resident 2), based on the facility ' s policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, by failing to: 1. Ensure nursing staff developed and implemented a CP for Resident 2 ' s use of physical restraint (any manual method, physical or mechanical device, equipment, or material that is attached or adjacent to a resident ' s body, cannot be easily removed by a residents, and restricts the resident ' s freedom of movement or access to their body) with a freedom splint (adjustable, multipurpose soft splints that helps restrict elbow movement to protect tubes, intravenous [IV- soft, flexible tube placed inside a vein to administer fluids and medication directly to the bloodstream] sites, or wounds) when an order for the restraint was placed on 8/16/2024. 2. Ensure Licensed Vocational Nurse (LVN) 7 developed and implemented CP for Resident 2…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two of six sampled residents (Resident 2 and Resident 3) electronic medical record (EHR) contained accurate and complete information by failing to: 1. Ensure staff completed and documented a Change of Condition (COC- a change in the resident's health or functioning that requires further assessment and intervention)/Interact Assessment Form (Situation-background-Assessment-Recommendation [SBAR- a written communication tool that helps provide essential, concise information, usually during crucial situations]) and a care plan (CP) after Resident 3 sustained a cut on the finger during trimming of fingernails. 2. Ensure Registered Nurse (RN) 1 and Licensed Vocational Nurse (LVN) 5 completed and documented a head-to-toe assessment, pain risk assessment (PRA), COC/SBAR form, and neurological checks (neuro checks- evaluates brain and nervous system function when there is accident, injury, or illness) after Resident 2 first fell on 8/19/2024 at…

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

Based on observation, interview, and record review, the facility failed to follow the facility's policy and procedure titled, COVID-19 (highly contagious disease caused by the SARS-CoV-2 virus that is spread through inhalation or contact of droplet particles into eyes, nose, or mouth) Policy by failing to: 1. Ensure Maintenance Worker (MW) 1 donned on (put on) personal protective equipment (PPE, equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) prior to entering a COVID-19 positive room. 2. Ensure Family Member (FM) 1 donned on PPE prior to entering a COVID-19 positive room. These failures had the potential to result in the spread of COVID-19 virus to residents, staff, and visitors in the facility. Findings: 1. During a concurrent observation and interview on 8/27/2024 at 12:39 PM in the hallway, MW 1 was observed to be in a COVID-19 positive room without a face shield. A purple sign was observed posted outside of the room that indicated Stop, Novel Respiratory Precautions (newly identified respiratory organism that causes acute…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 screen and offer the Coronavirus (COVID-19, highly contagious disease caused by the SARS-CoV-2 virus that is spread through inhalation or contact of droplet particles into eyes, nose, or mouth) vaccine to four of six sampled residents (Residents 1, 2, 4, and 5) as indicated in the facility's policy and procedure (P&P) titled, COVID-19 Policy. This failure had the potential to result in Residents 1,2,4, and 5 to develop COVID-19 and serious respiratory complications. Findings: 1. During a review of Resident 1's admission Record (AR), the AR indicated, Resident 1 was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included hyperlipidemia (high levels of cholesterol in the blood) and hypertension (HTN, high blood pressure). During a review of Resident 1's Immunization Record (IR) dated 2/6/2024, the IR indicated, Resident 1 was past due to receive the COVID-19 seasonal vaccine on 2/6/2024. 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 observation, interview, and record review, the facility failed to ensure a call light was within reach for one of six sampled residents (Resident 6). This deficient practice had the potential to result in the delay of care for Resident 6 when Resident 6 was unable to reach the call light to call staff for assistance. Findings: During a review of Resident 6's admission Record (AR), the AR indicated, the facility admitted Resident 6 on 5/24/2022, with diagnoses of hemiplegia (weak or paralyzed on one side of the body) and hemiparesis (weakness or inability to move on one side of the body) following nontraumatic subarachnoid hemorrhage (bleeding in the area between the brain and the thin tissues that cover and protect it) affecting right dominant side (the side of the body that is used more), respiratory failure (occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body) with hypoxia (lack of oxygen), and dysphagia (difficulty or discomfort in swallowing). During a review of Resident 6's Minimum Data Set (MDS, a standardized…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect the personal property of one of six sampled residents (Resident 3) from theft and loss by failing to inventory (make a complete list of) Resident 3's personal belongings on admission as indicated in the facility's policy and procedure (P&P) titled, Personal Property. This deficient practice placed Resident 3's personal belongings at risk of theft and loss and could negatively affect Resident 3's psychosocial well-being. Findings: During a review of Resident 3's admission Record (AR), the AR indicated, Resident 3 was originally admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis that included dementia (impaired ability to remember, think, or make decisions that interfere with doing everyday tasks). During a review of Resident 3's Inventory List - Resident Clothing and Possessions (ILRCP) on discharge date d 1/15/2024, timed at 10:34 AM, the ILRCP indicated, Resident 3 was discharged with three blankets, one feet…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 one of six sampled residents (Resident 2) remained free from physical restraint (any manual method, physical or mechanical device, equipment, or material that is attached or adjacent to a resident's body, cannot be easily removed by a residents, and restricts the resident's freedom of movement or access to their body) for use of convenience (the result of any action that has the effect of alerting a resident's behavior and requires a lesser amount of care or effort, and is not in a resident's best interest) as indicated in the facility's policy and procedure (P&P) titled, Physical Restraint, by failing to: 1. Ensure Registered Nurse (RN) 4, Licensed Vocational Nurse (LVN) 2, LVN 6, and Certified Nurse Assistant (CNA) 3 did not wrap a towel around Resident 2's right arm and inside the freedom splint (adjustable, multipurpose soft external device that helps restrict elbow movement), causing the splint to further restrict Resident 2'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 care and services to prevent a fall (move downward, typically rapidly and freely without control, from a higher to a lower level) for one of six sampled residents (Resident 2), who was at high risk for falls, and as indicated in the facility's policies and procedures (P&P) titled, Safety and Supervision of Residents, and Falls and Fall Risk, Managing, by failing to: Ensure Resident 2's bed alarm/pad alarm (sensor pad device placed under a resident's bottom containing sensors that triggers an alarm when it detects a change in pressure, used as an early alert when a resident is trying to get out of bed) was working/functioning on the morning of 8/28/2024 prior to Resident 2 sustaining a fall. As a result of this failure, on 8/28/2024 at approximately 5:40 am, Resident 2 fell to the floor, Resident 2's medical pole (a device that holds a bag(s) of Gastrostomy Tube [G-tube- tube inserted through the belly that brings nutrition…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 education for the Influenza (the Flu, contagious respiratory illness that affects the nose, throat, and lungs which can be prevented by getting the Flu vaccine) vaccine for one of six sampled residents (Resident 5). This failure had the potential to result in Resident 5 and/or Resident 5's responsible party being unaware of the benefits and potential side effects of the Flu vaccine. Findings: During a review of Resident 5's admission Record (AR), the AR indicated, Resident 5 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), chronic kidney disease (gradual loss of kidney function), and hypertension (high blood pressure) During a review of Resident 5's History and Physical (H&P, formal document of a medical provider's examination of a patient), dated 7/18/2024, the H&P 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 observation, interview, and record review, the facility failed to ensure standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) were followed in accordance with the facility's policy and procedure and the Centers for Disease Control and Preventions (CDC- the nation's leading science-based, data-driven, service organization that protects the public's health) guidelines by failing to: 1. Ensure five of seven sampled staff members (Certified Nursing Assistant [CNA] 1,CNA 2, CNA 3, Housekeeper [HK] 1, and Registered Nurse Supervisor [RNS] 1 performed hand hygiene (procedures that included the use of alcohol-based hand rubs [ABHR- an alcohol-containing preparation designed for application to the hands to inactivate microorganisms and/or temporarily stop their growth] and/or hand washing with soap and water) before entering residents rooms and after providing care to three of five sampled residents (Residents 2,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to promptly (punctually [with little or no delay]) notify the responsible party (RP) for one of five sampled residents (Resident 3) who experienced a change of condition (COC- a sudden clinically important deviation from a resident/patient's baseline in physical, behavioral, or functional domains), as indicated in the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 2 notified Resident 3's RP (RP 1), promptly when LVN 2 noted bruising (mark on the skin caused by blood trapped under the surface because of injury to small blood vessels but does not break the skin) to Resident 3's right knee on 7/15/2024 at 2:34 pm. 2. Ensure facility staff notified RP 1 on 7/17/2024 when the results of Resident 3's electromagnetic radiation (X-ray- type of radiation that creates picture of the inside of the body) showed that Resident 3 sustained a fracture (a complete or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an injury of unknown origin/source (the source of the injury was not observed by any person and could not be explained by the resident) immediately, but not later than 24 hours to the Administrator (ADM) of the facility, the California Department of Public Health (CDPH), local law enforcement, and Ombudsman (resident advocate who investigates, reports, and helps settle complaints) as indicated in the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating, for one of five sampled residents (Resident 3). This failure violated the mandated reporting timeframe and had the potential to compromise Resident 3's safety and could result in further injuries potentially related to abuse for Resident 3. Findings: During a review of Resident 3's admission Record (AR), the AR indicated, the facility admitted Resident 3 to the facility on [DATE], with diagnoses 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 follow its policy and procedure (P&P) titled, Nail Care, for two of five sampled residents (Residents 1 and 3) by failing to: 1. Ensure assigned Certified Nursing Assistants (CNAs) trimmed and cleaned the fingernails of Resident 1 who required substantial/maximal assistance (helper did more than half the effort, helper lifted or held trunk or limbs and provided more than half the effort) with personal hygiene. 2. Ensure assigned CNAs notified assigned Licensed Vocational Nurses (LVNs) regarding Resident 1's and Resident 3's long and overgrown toenails. 3. Ensure assigned LVNs notified the Social Services Assistant (SSA) that Resident 1 and Resident 3 needed to be referred and seen by a podiatrist (medical specialist who helps with problems that affect the feet or lower legs) for cleaning and trimming of Resident 1's and Resident 3's long and overgrown toenails. These failures had the potential to cause injuries and infections to Resident…

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

Based on interview and record review, the facility failed to provide copies of Resident's medical record requested from the Representing Party (RP) for one of three residents (Resident 1). This failure violated Resident 1's right and resulted in Resident 1's PR received Resident 1's medical record six days late. Findings: A review of Resident 1's admission Record, indicated the facility initially admitted Resident 1 to the facility on 5/9/2024 with diagnoses that included chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs). A review of Resident 1's History and Physical dated 5/12/2024, indicated the Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's Authorization form For the Release of Medical Information Health Insurance Portability and Accountability Act (HIPPA COMPLIANT) (Federal regulation that outline how protected health information (PHI) can be used and disclosed in the United Stated), dated 5/21/2024, indicated authorization for release of medical records…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident's Advance Directives (AD, a written preferences regarding treatment options, a process of communication between individuals and their healthcare agents to understand, reflect on, discuss, and plan for future healthcare decisions for a time when individuals are not able to make their own healthcare decisions) and Consent for Medical Treatment (CMT, permission given before a resident receive any type of medical treatment, test or examination) were discussed and written information were provided to the residents and/or responsible parties for three of four sampled residents selected for advance directives care area (Residents 18, 192 and 35) in accordance with the facility's policy and procedure. These failures had the potential for facility staff to provide medical treatment and services against the resident's will. Findings: a. During a review of Resident 18's admission Record (AR), the AR indicated Resident 18 was admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY During observation, interview, and record review, the facility failed to provide care and services to promote the healing of pressure ulcers (lesion/wound caused by unrelieved pressure that results in damage of underlying tissue) for three of four sampled residents (Residents 78, 241 and 35.) with existing pressure ulcers by failing to: a. Turn and reposition Residents 78 and 241 with an existing Stage 4 pressure ulcer (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle). Residents 78 and Resident 241 required assistance with turning and repositioning. b. Ensure Resident 35's Low Air Loss Mattress (LAL- a bed mattress designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) static setting was turned off while Resident 35 was lying in bed. These deficient practices had the potential to delay healing of Residents 78, 241 and 35's pressure ulcer. Findings: a. During a review of Resident 78's admission Record (AR), the AR 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 all nursing staff possess the competencies (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles successfully) and skill sets necessary to meet the residents' needs safely when the facility failed to: a. Ensure the competency skills evaluation included pressure ulcer prevention and management for two of two sampled Certified Nursing Assistants (CNAs 3 and 4). b. Ensure all direct care staff received in-service regarding pressure ulcer prevention and management that would include turning and repositioning and the operation of the low air loss mattress (LAL- a bed mattress designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown.) Findings: a. During an interview on 5/10/2024 at 3:06 pm, CNA 3 stated she did not receive training at the facility regarding pressure ulcer prevention and management. During a review of CNA 3's employee file on 5/10/2024 at 3:11 pm, the employee file…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safe and sanitary environment to help prevent the development and transmission of communicable diseases (one that is spread from one person to another) for eight of eight sampled residents (Residents 191, 39, 38, 32, 30, 70, 8, and 2) selected for infection control care area, by failing to: a. Ensure signage was posted and PPE cart was provided to Resident 191 with a gastrostomy tube (GT, a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) on Enhanced Standard Precaution (ESP, an approach for the use of personal protective equipment [ PPE- specialized equipment or clothing that protects against infectious materials] to reduce transmission of multidrug-resistant organisms [MDRO] between residents in skilled nursing facilities) in accordance with the facility's policy and procedure (P&P) and resident's care plan. b. Ensure signage was posted and PPE…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, Resident 33's notice of Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) of non-coverage did not have documented evidence of an informed decision from Resident 33's responsible party to pay for non-covered services after Resident 33 was discharged from Medicare Part A and Resident 33 continue to reside in the facility for one of one sampled resident (Resident 33). This deficient practice placed Resident 33 at risk for payment of out-of-pocket costs for non-coverage services while in the facility. Findings: During a review of Resident 33's admission Record (AR), the AR indicated the facility readmitted Resident 33 on 3/6/2024, with diagnoses that included dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning), chronic obstructive pulmonary disease ([COPD] a group of lung diseases that block airflow and make it difficult to breathe) and schizoaffective disorder (a mental disorder characterized by abnormal thought processes and an unstable mood). During…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 certified nurse assistant (CNA) failed to protect the resident's rights by not closing the privacy curtain to ensure the resident was not visually exposed to the roommate while the CNA was cleaning the resident for one of one sampled resident (Resident 34) selected for privacy care area. This failure resulted in the violation of the resident's right for privacy. Findings: During a review of Resident 34's admission Records (AR), the AR indicated Resident 34 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included hemiplegia (paralysis or weakness on one side of the body), hemiparesis (loss of strength on one side of the body) and cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain). During a review of Resident 34's untitled Care Plan (CP), dated 3/25/2020, the CP indicated Resident 34 had self-care deficit for activities of daily living (ADL, activities related to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to assess and monitor the presence of white sediments (visible particles in the urine that could indicate infection or dehydration [fluid deficit]) in the urine for one of one sampled residents (Resident 58) with indwelling catheter (foley catheter [FC] - a tube inserted in the bladder to drain urine into a drainage bag) as indicated in the facility's policy and procedure, titled Foley Catheter Guidelines for Preventing Catheter Associated Urinary Tract Infections (CAUTI's) and the resident's care plan. This deficient practice had the potential for Resident 58 to receive no care or delayed care and treatment for urinary tract infection (UTI, condition in which bacteria invade and grow in any part the urinary system). Findings: During a review of Resident 58's admission record (AR), the AR indicated the facility admitted Resident 58 on 4/22/2022 and readmitted on [DATE] with diagnoses that included pressure ulcer stage four (ulcer that extends…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 necessary care and services for gastrostomy tube (GT, a tube inserted through the abdomen that delivers nutrition directly to the stomach) site as ordered by the physician and as indicated in the plan of care for one of one sampled resident (Resident 26) selected for tube feeding care area. This failure had the potential for complications related to tube feedings for Resident 26. Findings: During a review of Resident 26's admission Records (AR), the AR indicated Resident 26 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included gastrostomy (an opening into the stomach from the abdominal wall), dysphagia (difficulty swallowing), and tracheostomy (an incision in the windpipe made to relieve an obstruction to breathing). During a review of Resident 26's Care Plan (CP) titled Tube Feeding, initiated 8/19/2022, the CP indicated, Resident 26 was getting nutrition and hydration by GT feeding. The CP…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the dialysis (procedure to remove wastes or toxins from the blood and adjust fluid and electrolyte imbalances) emergency kit was readily available at the bedside for one of one sampled resident (Resident 51). This deficient practice had the potential for adverse consequences in the event of emergency bleeding from the dialysis access site for Resident 51. Findings: During a review of Resident 51's admission Record, the record indicated the facility admitted the resident on 4/12/2024, with diagnoses that included end stage renal disease ( ESARD a medical condition in which a person's kidneys cease functioning on a permanent basis) and type 2 diabetes mellitus (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in elevated levels of glucose/sugar in the blood and urine.) During a review of Resident 51's Minimum Data Set (MDS - a standardized assessment and care planning 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 one of five sampled residents (Resident 33) on psychotropic drugs (any drug that affects brain activities associated with mood, emotions, and behavior) was free from unnecessary medications by failing to ensure staff attempted a gradual dose reduction ([GDR] the stepwise tapering of a dose to determine if symptoms, condition, or risks can be managed by a lower dose or if the dose or medication can be discontinued) of Resident 33's Quetiapine Fumarate ([antipsychotic drug] a drug use to treat symptoms of psychosis or disconnection from reality) 25 milligram ([mg] unit of measurement) since ordered on 9/9/2022. This deficient practice placed Resident 33 at risk for adverse drug reaction (a harmful and unintended response to a medicine). Findings: During a review of Resident 33's admission Record (AR), the AR indicated the facility readmitted Resident 33 on 3/6/2024, with diagnoses that included dementia (long term and often gradual…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 its binding arbitration agreements included selection of a neutral arbitrator and a venue convenient to both facility and resident/resident responsible party for two of two sampled residents (Residents 33 and 50). This deficient practice placed Residents 33 and 50 at risk for an unjust arbitration and delayed arbitration hearing in an event of an arbitration dispute. Findings: a. During a review of Resident 33's admission Record (AR), the AR indicated the facility readmitted Resident 33 on 3/6/2024, with diagnoses that included dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning), chronic obstructive pulmonary disease ([COPD] a group of lung diseases that block airflow and make it difficult to breathe) and schizoaffective disorder (a mental disorder characterized by abnormal thought processes and an unstable mood). During an observation on 5/7/2024…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 its abuse Policy and Procedure for Abuse Allegation Reporting for two of three sampled residents (Residents 1 and 3) by failing to: 1. Report an incident of injury of unknown origin which occurred on 12/25/23 to Resident 1 to the California Department of Public Health (CDPH) Licensing and Certification (State Agency) within two hours. 2. Report an incident of injury of unknown origin which occurred on 12/24/23 to Resident 3 to the California Department of Public Health Licensing and Certification. These deficient practices had the potential for delayed abuse investigation for Residents 1 and 3. Findings: During a review of Resident 1's admission Record, the admission record indicated Resident 1 was originally admitted on [DATE] and was readmitted on [DATE], with diagnoses that included paraplegia (impairment in motor or sensory function of the lower extremities) and dementia (loss of cognitive functioning such as thinking,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) were followed in accordance with the facility's policy and procedures by failing to: 1. Ensure three of five sampled staff (Certified Nurse Assistants [CNA] 1, Housekeeping Staff (HS) 1, and CNA 2) wore appropriate personal protective equipment (PPE- equipment worn to minimize exposure to a variety of hazards) when entering residents' room who were on transmission-based precautions (TBP- used when a resident is suspected or known to be infected with infectious agents, and require additional control measures to prevent transmission). 2. Ensure the appropriate TBP signage were posted outside of Resident 1 and Resident 2's room indicating the specific type of PPE needed before entering the rooms. 3. Ensure one of five sampled residents (Resident 2) who tested positive for COVID-19 (infectious…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Census and Direct Care Service Hours Per Patient Day (DHPPD) and Staffing Posting were updated and posted daily at the beginning of each shift for in accordance with the facility ' s policy and procedures for two of three sampled stations. This failure resulted in the facility DHPPD/Staffing Posting not being updated and accurate for residents and visitors in a readable format on 9/11/2023. Findings: During a concurrent observation and interview on 9/11/2023 at 8:55 AM with the Director of Nursing (DON) on the second floor, Nurses Station, the DON stated, the DHPPD/Staffing Posting posted for both Skilled Nursing Unit and Sub-Acute Unit were not updated or changed to reflect the current date. The DON stated, the Skilled Nursing Unit DHPPD indicated the date 9/9/2023. The DON stated, the Sub-Acute Unit ' s Staffing Posting indicated the date 9/8/2023. During an interview, on 9/11/2023 at 9:15 AM, the DSD stated, she was responsible for updating and posting the staffing information daily. DSD 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide incontinent (unable to hold urine or feces) care to two of two sampled residents (Resident 1 and Resident 2). This deficient practice had the potential for skin breakdown for Resident 1 and resulted to hyperpigmentation (skin darkening) with scarring (a growth of tissue marking the spot where skin has healed) on the perianal (area around the anus) area for Resident 2. Findings: a.During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 9/10/2022, with diagnoses that included age related osteoporosis (brittle bones) and Alzheimer's disease (a brain disorder that causes a gradual decline in memory, thinking, behavior and social skills). During a review of Resident 1's care plan on ADL/self-care deficit revised on 12/15/2022, the care plan indicated for staff to assist Resident 1 with toileting needs and/or provide incontinent care after incontinent episodes. The care plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure sufficient nursing staff was available to provide nursing related services to two of three sampled residents. This deficient practice resulted in the failure to provide incontinent care to Residents 1 and 2 and Resident 2 developed skin discoloration with raised bumps on the perianal (area around the anus) area. Findings: a. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 9/10/2022, with diagnoses that included age related osteoporosis (brittle bones) and Alzheimer's disease (a brain disorder that causes a gradual decline in memory, thinking, behavior and social skills. During a review of Resident 1's Minimum Data Set (MDS- a standardized assessment and care planning tool) dated 6/12/2023, the MDS indicated Resident 1 had severe cognitive (ability to understand) impairment. The MDS indicated Resident 1 required extensive assistance (resident involved 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.