Golden Pavilion Healthcare

Based on observation, interview, and record review, the facility failed to thoroughly investigate a change in condition for one of three sampled resident (resident 1) when Resident 1 developed bruises to the left forearm and on top of the left hand with unknown origin. The facility failure has the potential for Resident 1 to not receive the necessary care and services. Findings: A review of the admission records indicated Resident 1 was admitted with diagnoses including end stage renal (kidney) failure (when the kidneys stopped working) and dementia (decline in memory or other thinking skills). A review of the nurses' notes dated 12/7/24, indicated, Resident 1 was noted with discoloration on the: left forearm measuring six (6) centimeters (cm, a unit of measurement) by (X) three (3) cm, top of left-hand site 1: 2.5 cm X two (2) cm, top of left-hand site 2: One (1) X one cm. A review of the physician order dated 12/7/24, indicated, to monitor discoloration on the left lower arm and to apply ice pack to the left wrist. A review of the care plan intervention dated 12/7/24, 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 develop a comprehensive plan of care for one of three residents (Resident 1) when osteopenia (bone density loss, weak bones) was not addressed. The facility failure has the potential for Resident 1 to not receive necessary care and services. Findings: A review of the admission records indicated Resident 1 was admitted with diagnoses including end stage renal (kidney) failure (when the kidneys stopped working) and dementia (decline in memory or other thinking skills) and history of fractures (broken bones). A review of the Orthopedic notes dated 9/17/24, indicated, an Xray (a test that takes a pictures of the structures inside the body particularly the bones) result from 7/16/24 as followed: .Significant osteopenia evident along with degenerative changes about the wrist. During an interview on 1/10/25, at Assistant Director of Nursing reviewed the care plan for Resident 1 and stated that she did not see a care plan to address osteopenia. During an interview on 1/17/25, at 10:00 AM, the Director of Nursing stated that 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.

Based on interview and record review, the facility failed to train and review the performance of three out of three sampled Certified Nursing Assistants (CNAs) when employee files of CNA 1, CNA 2, and CNA 3 lacked documentation of initial training as well as a performance review required by facility policy and procedure. This failure has the potential to result in untrained CNAs providing unsafe care that could cause harm to Residents. Findings: A review of a documented titled New Hire Report dated 10/01/23 to 11/30/23 indicated that CNA 1, CNA 2, and CNA 3 were all hired in October of 2023. It further indicated that CNA 1 ended employment on April 2024; CNA 2 ended employment on March 2024; CNA 3 ended employment on February 2024. During a concurrent interview and record review on 10/02/24 at 10:35 AM with the Director of Staff Development (DSD), CNA 1 ' s employee file was reviewed. The DSD stated that after someone is hired, they will have two days of classroom orientation that includes topics about patient care. The DSD stated that this classroom instruction should be completed…

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 retain personal possessions of Resident 1, one of two sampled residents, when after return from hospitalization Resident 1's two head phones, one Blue Tooth speaker/microphone and two full Lysol disinfectant spray cans were missing from his closet. This failure resulted in depression, disappointment, and mental anguish to the resident. Findings: Resident 1 was admitted to the facility on [DATE], initial admission on [DATE], with diagnoses including osteomyelitis of vertebra, sacral region (bone infection of spine), pressure ulcer of sacral region (wound on lower back area), diabetes mellitus, heart failure, chronic pain syndrome, functional quadriplegia (complete immmobility of limbs), and history of pulmonary embolism (blocked artery in lungs). Review of resident''s MDS (Minimum Data Set) an assessment tool, indicated Resident 1 had good cognition (thinking ability), had clear speech and good hearing, required assistance to roll side to side, unable…

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 resident's right to be free from neglect when Resident 1, one of two sampled residents, was deprived of care and did not receive a sponge bath for one month. This failure resulted in discomfort, humiliation, and embarrassment to the resident. Findings: Resident 1 was admitted to the facility on [DATE], initial admission on [DATE], with diagnoses including osteomyelitis of vertebra, sacral region (bone infection of spine), stage 4 pressure ulcer of sacral region (wound on lower back area), diabetes mellitus, heart failure, chronic pain syndrome, functional quadriplegia (complete immobility of limbs), and history of pulmonary embolism (blocked artery in lungs). Review of resident's MDS (Minimum Data Set) an assessment tool, indicated Resident 1 had good cognition function (thinking ability), had clear speech and good hearing, required staff assistance to roll side to side, was unable to sit, stand, or walk. Required staff assistance for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide prn medication (as needed) on time to Resident 1, one of two sampled residents, when the resident waited for pain relief caused by pressure ulcer (wound infection in lower back) and bone infection. This failure caused the resident unnecessary pain, discomfort, and anxiety. Findings: Resident 1 was admitted to the facility on [DATE], initial admission on [DATE], with diagnoses including osteomyelitis of vertebra, sacral region (bone infection of spine), pressure ulcer of sacral region (wound on lower back area), diabetes mellitus, heart failure, chronic pain syndrome, functional quadriplegia (complete immobility of limbs), and history of pulmonary embolism (blocked artery in lungs). Review of resident's MDS (Minimum Data Set) an assessment tool, indicated Resident 1 had good cognition function (thinking ability), had clear speech and good hearing, required assistance to roll side to side, unable to sit, stand, or walk. Required staff assistance…

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 investigation, and results, related to abuse, neglect or mistreatment, when Resident 1, one of one sampled residents, was injured when she was dropped on the floor and her tooth was broken. For alleged violations of neglect or mistreatment that do not result in serious bodily injury the facility must report the allegation no later than 24 hours. The facility must provide in its report sufficient information to describe the alleged violation and indicate how residents are being protected. Within 5 working days of the incident, the facility must provide sufficient information to describe the results of the investigation and indicate any corrective actions taken. Any updates should be included. This failure showed no action was taken for the injury to the Residents tooth. Notice of violation was never made to the California Department of Public Health. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses including kidney…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Resident 1, one of one sampled resident, was assisted to obtain or was reimbursed for eyeglasses after staff lost three pairs of residents prescription eyeglasses. Resident has glaucoma and vision difficulties. This failure resulted in creating depression and additional visual difficulties for the resident. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses including kidney disease, heart failure, diabetes, gait and mobility abnormalities, and glaucoma. Resident 1's Minimum Data Set, MDS, an assessment tool, indicated resident had no hearing difficulties, had cognitive impairment (thinking ability), required a two-person assist to move and reposition in bed, to transfer to chair/wheelchair and to dress. Resident 1 weighs 89 pounds, is 5 feet tall, [AGE] years old, and does not walk. During an interview on 7/11/2024, at 4:04 PM, resident 1's son stated the facility has lost the residents eyeglasses, at least, three times.…

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 foot care (podiatrist service) was provided to Resident 1, one of one sampled resident, when she did not receive any foot care service, e.g,, toe nail clipping, since admission, for 2 1/2 years, and has a condition that poses a risk to foot health (e.g., diabetes) this resulted in immobility, and overgrown, uncomfortable toe nails and feet. This failure resulted in neglect to the resident, caused pain, and loss of ability to walk. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses including kidney disease, heart failure, diabetes, gait and mobility abnormalities, and glaucoma. Resident 1's Minimum Data Set, MDS, an assessment tool, indicated resident had no hearing or vision difficulties, had cognitive impairment (thinking ability), required a two-person assist to move and reposition in bed, to transfer to chair/wheelchair and to dress. Resident 1 weighs 89 pounds, is 5 feet tall, [AGE] years old, and does not walk.…

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 assist Resident 1, one of one sampled resident, to obtain dental care for a facility caused tooth injury, due to fall, for nine months. Facility must refer resident promptly, within 3 days, for dental services. This failure resulted in lack of care and services for nine months to resident. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses including kidney disease, heart failure, diabetes, gait and mobility abnormalities, and glaucoma. Resident 1's Minimum Data Set, MDS, an assessment tool, indicated resident had no hearing difficulties, had cognitive impairment (thinking ability), required a two-person assist to move and reposition in bed, to transfer to chair/wheelchair and to dress. Resident 1 weighs 89 pounds, 5 feet tall, [AGE] years old, and does not walk. During a telephone interview with Resident 1's son on 7/11/2024 at 4:04 PM, son stated in October, 2023, the facility staff dropped his mother on the floor and broke her…

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 result of its investigation of the abuse allegation involving two residents (Resident 1 and Resident 2) on 1/29/24 was reported within five working days of the occurrence of the alleged incident to the State Survey Agency. This failure violated the federal mandated reporting time frame. Findings: Resident 1's admission Record indicated she was admitted on [DATE] and was discharged on 1/30/24. Review of Resident 1's Skilled Charting, dated 1/29/24 at 4:36 PM, indicated Pt (patient, also referred to a resident [referring to Resident 1]) called the police [NAME] (because) pt said she was verbally abused by roommate (referring to Resident 2) . Resident 2's admission Record indicated she was admitted on [DATE] and discharged on 3/11/24. Review of Resident 2's Skilled Charting, dated 1/29/24 at 4:10 PM, indicated Pt (Resident 2) had an argument with roommate (referring to Resident 1). (Resident 1) called the police for being verbally abused by 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 treat Resident 1, one of one sampled resident, with dignity and respect when resident waited on the nurse call light over one hour for pain medications on two successive evenings and failed to provide pain management relief, in a timely manner when resident waited over an hour for pain medication for his leg wound on two occasions during the evening shift. This failure caused the resident pain and suffering, violation of his rights and decreased feelings of well-being. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, urinary tract infection, urinary catheter, gait and mobility abnormalities, colostomy status (an opening in the intestine through the abdominal wall), and chronic pain syndrome. Review of Resident 1 ' s MDS (Minimum Data Set) an assessment tool, showed resident has clear speech, hearing, and adequate vision. Resident has a cognition score (thinking ability) of 15. The highest score…

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 pain management relief, in a timely manner, for Resident 1, one of one sampled resident, when resident waited over an hour for pain medication for his leg wound on two occasions during the evening shift. This failure resulted in unnecessary pain and suffering and decreased feelings of well-being for the resident. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, urinary tract infection, urinary catheter, gait and mobility abnormalities, colostomy status (opening in the intestine through the abdominal wall), Right leg wound with graft, and chronic pain syndrome. Review of Resident 1 ' s MDS (Minimum Data Set) an assessment tool, showed resident has clear speech, good hearing, and adequate vision. Resident has a cognition score (thinking ability) of 15. The highest score achievable. Resident has lower extremity impairment of both feet and cannot walk. During an interview, in the facility, 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 interviews and facility policy review, the facility failed to implement their Legionella (a pathogenic gram-negative bacteria) water management program. This had the potential to affect all 229 residents residing in the facility. Findings included: A review of a facility policy titled, Legionella Water Management Program, revised in September 2022, revealed, Our facility is committed to the prevention, detection and control of water-borne contaminants, including Legionella. Policy Interpretation and Implementation 1. As part of the infection prevention and control program, our facility has a water management program, which is overseen by the water management team. 2. The water management team consists of at least the following personnel: a. The infection preventionist; b. The administrator; c. The Medical Director (or designee); d. The director of maintenance; and e. The director of environmental services. 3. The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk 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 observations, interviews, record review, and facility policy review, the facility failed to ensure confidential medical information was kept private for 1 (Resident #185) of 4 sampled residents reviewed for dignity. Specifically, the facility failed to remove visible wristbands that identified medical information about the resident after Resident #185 was readmitted from the hospital. Findings included: A review of a facility policy titled, Resident Rights, revised in February 2021, revealed, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: privacy and confidentiality. The policy further specified, The unauthorized release, access, or disclosure of resident information is prohibited. A review of an admission Record revealed the facility admitted Resident #185 on 06/19/2023 and most recently readmitted the resident on 04/01/2024 with diagnoses that included abnormalities of gait and mobility and abnormal posture. 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 record review, interviews, and facility document and policy review, the facility failed to report an allegation of physical abuse involving 1 (Resident #197) of 4 sampled residents reviewed for abuse to the California Department of Public Health (CDPH) within two hours. Findings included: A review of a facility policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised in September 2022, revealed, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. The policy indicated, 1. If resident abuse, neglect, exploitation, misappropriate of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. The policy further indicated, 3. Immediately is defined as: a. within two hours of an allegation involving…

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 record review, interviews, and facility policy review, the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected the use of an antipsychotic medication and physical behaviors directed towards others for 1 (Resident #197) of 2 sampled residents reviewed for behaviors and accurately reflected the discharge location for 1 (Resident #237) of 3 sampled residents reviewed for discharges. Findings included: A review of a facility policy titled, Certifying Accuracy of the Resident Assessment, revised in November 2019, revealed, Any person completing a portion of the Minimum Data Set/MDS (Resident Assessment Instrument) must sign and certify the accuracy of that portion of the assessment. The policy further indicated, 3. The information captured on the assessment reflects the status of the resident during the observation (look-back) period for that assessment. Different items on the MDS may have different observation periods. 1. A review of an admission Record revealed the facility…

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

Based on interview, record review, and facility document and policy review, the facility failed to complete a new Level I Preadmission Screening and Resident Review (PASARR) after residents were diagnosed with a new mental illness for 2 (Resident #41 and Resident #164) of 4 sampled residents reviewed for PASARR requirements. Findings included: A review of a facility policy titled, admission Criteria, revised in March 2019, revealed, 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. A review of a facility policy titled, Change in a Resident's Condition or Status, revised in February 2021, revealed, 7. In addition to notifying the resident and/or representative, the state mental health agency or state intellectual disability agency will be notified within 24 hours of a significant change in the mental or physical condition of a resident with a mental disorder or intellectual disability. A review of Resident #41'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.

Based on interviews, record review, facility policy review, and review of the California Department of Health Care Services Preadmission Screening and Resident Review (PASRR) Level I Assessment Guide, the facility failed to ensure a Level I Preadmission Screening and Resident Review (PASARR) was accurately completed for 1 (Resident #139) of 4 sampled residents reviewed for PASARR requirements. Specifically, the facility failed to ensure Resident #139's Level I PASARR Screening reflected the presence of a serious diagnosed mental disorder. Findings included: A review of a facility policy titled, admission Criteria, revised in March 2019, revealed, 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. A review of the California Department of Health Care Services Preadmission Screening and Resident Review (PASRR) Level I Assessment Guide, dated 01/12/2023, revealed, Section III-Serious Mental Illness Questions 10-12 This…

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 record review, interviews, and facility policy review, the facility failed to ensure staff administered medication as ordered by the physician for 1 (Resident #180) of 1 sampled resident reviewed for medication concerns. Findings included: A review of a facility policy titled, Administering Medications, revised in April 2019, revealed, Medications are administered in a safe and timely manner, and as prescribed. The policy specified, 4. Medication are administered in accordance with prescriber orders, including any required time frame. A review of Resident #180's admission Record revealed the facility admitted the resident on 05/18/2023 with diagnoses that included unspecified atrial fibrillation (an irregular, often rapid heart rate). A review of Resident #180's Care Plan revealed a Focus area, initiated on 05/18/2023, that indicated the resident had impaired cardiac and/or circulatory function with risk for complications related to a history of cerebrovascular accident (CVA, stroke), hypertension (high blood pressure), and atrial fibrillation. An intervention dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised based on the needs of the resident and in response to current interventions for one of five sampled residents (Resident 1). This deficient practice does not ensure plan of care was evaluated for effectiveness to prevent reoccurrence of physical aggression that could result to harm or serious injury to other residents and staff. Findings: Resident 1 was admitted on [DATE] with diagnoses including Alzheimer's disease (the most common type of dementia, a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment, involves parts of the brain that control thought, memory, and language). Review of Resident 1's Minimum Data Set (MDS - an assessment tool) dated 11/26/23 indicated, Resident 1 was cognitively impaired. Review of Resident 1's clnical record, admission H&P (History and Physical) dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record reviews, the facility failed to provide goods and services such as the call lights to three residents to meet their needs by its staff when: 1) Resident 1, Resident 2 and Resident 3 were found to have their call lights not within reach and was found disconnected from the wall socket. 2) The facility did not ensure an orientation and training was implemented on general guidelines in answering the call light. These failures will result to an environment that promotes neglect. Neglect occurs when the facility is aware of, or should have been aware of, goods or services that a resident(s) require but the facility fails to provide them to the resident(s) resulting in, or may result in, physical harm, pain, mental anguish, or emotional distress. FINDINGS: During a review of Resident 1's admission record dated 12/13/23, indicated the resident was admitted to the facility with diagnoses of: Hypertensive heart disease (a constellation of changes in the left ventricle, left…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop a comprehensive care plan for the two residents that included measurable objectives and specific interventions when: Resident 1. The call light in Resident 1's room (all three beds) was found disconnected from the wall socket and was not within the residents' reach. Resident 2. Had a resident to resident altercation. Resident B was the abuser. No care plan was developed for this resident-to-resident abuse. This failure has the potential for not meeting the residents' goals of care to meet their highest practicable well-being. FINDINGS: 1. During a review of Resident 1's admission record dated 12/13/23, indicated the resident was admitted to the facility with diagnoses of: Hypertensive heart disease (a constellation of changes in the left ventricle, left atrium, and coronary arteries as a result of chronic blood pressure elevation), chronic kidney disease (CKD means your kidneys are damaged and can't filter blood the way they should), and type 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.

Based on observation, interviews, and record reviews the facility failed to ensure the allegation of resident-to-resident abuse was promptly reported to the State Agency (SA, which is the California Department of Public Health, CDPH) in accordance with the facility's policy and procedure for two of four sampled residents (Residents 2 and 3). Failure to promptly report allegation of abuse had the potential for further abuse to happen and thereby increasing the chances of harm to the residents. Findings: In an interview on 11/14/23, at 9:42 AM, Resident 2 was awake sitting up in her bed. Resident 2 stated, she remembered the day her roommate (Resident 3) hit on her head with her bare fist. It was lunch time when Resident 3 walked to her table, she was talking in non-English language. Resident 3 picked and messed with her food on her lunch tray, she told Resident 3 to stop and thought she (Resident 3) would go back to her bed. Resident 2 stated, she turned her head to the window and Resident 3 hit her on the right side with her (Resident 3) bare fist. Review of the Resident 3'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 the facility failed to ensure the accuracy of assessment for one of four (4) sampled residents (Resident 1) when the Quarterly Minimum Data Set (MDS, as assessment tool) dated 9/27/23, did not reflect the Residents 1's on-going chronic pain. This deficient practice had the potential to delay the delivery of care and could result in the decline in resident's condition. Findings: Review of the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and was re-admitted on [DATE]. The History and Physical, dated 7/6/23 indicated, Resident 1 was initially 'admitted due to weakness, and now readmitted for UTI (Urinary tract infection, an infection in any part of the urinary system), and the other diagnoses included, chronic pain syndrome, abnormal gait and posture, urinary retention (inability to completely empty the bladder of urine), and right leg cellulitis (deep infection of the skin caused by bacteria). In an observation and interview 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 ensure the Medication Drug Regimen (also known as Drug Regimen Review [DDR], a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) for one of four (4) sampled residents (Resident 1), who received as needed doses of Hydromorphone (strong opioid-based pain medicine), were reviewed for drug irregularities when: 1. The facility consistently administered as needed doses of Hydromorphone for chronic muscular pain without conducting a thorough Drug Regimen Review (DRR). Without proper evaluation, there was a lack of oversight on the frequency and appropriateness of administering Hydromorphone. This failure to assess the necessity of each dose could lead to potential overuse and excessive dosing. 2. The Physician's order for Hydromorphone lacked a pain scale (a tool to measure pain intensity to improve…

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 prevent unnecessary use of medication for one of four (4) sampled residents (Resident 1) when: 1.The facility failed to monitor and assess the effectiveness of the pain management regimen for Resident 1. Despite ongoing complaints of pain, there was no indication of adequate monitoring or adjustment to the medication regimen. This lack of monitoring resulted in the persistence of the resident's pain, indicating a failure in the overall management of the medication regimen. Resident 1 felt pain was still staying even after the doses of the pain medication were administered, it was there all the time, it never goes away. 2. Doses of Hydromorphone (a strong opioid-based pain medicine) were administered for Pain Scale (PS, a tool to measure pain intensity to improve communication and understanding about the pain a person may be experiencing) of 0/10 (a score of 0 means no pain, and 10 means the worst pain a person have ever felt) on certain days for the months of August, September, October, and November 2023. This deficient…

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 one of 47 sampled residents (Resident 2) access to communication with staff and visitors in a language that is clear and understandable to the resident when a language translation service was not available for use by the resident. This deficient practice resulted in Resident 2 feeling frustrated for being unable to communicate with staff and relaying his needs and concerns and had the potential for the 47 residents with limited proficiency in English to not have access to communication with persons inside and outside the facility. Findings: Review of facility document, titled Languages List, dated 12/19/23 indicated that there are 47 residents whose primary language is not English and are listed as needing interpreter. Review of Resident 2's admission Record, indicated Resident 2 was admitted on [DATE] with diagnoses that include generalized anxiety disorder (persistent and excessive worry that interferes with daily activities)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record reviews, the facility failed to notify the resident representative (RP) of one of three sampled residents (Resident 1) when Resident 1 had a fall incident and a discoloration on his left forearm. This deficient practice prevented Resident 1's representative in participating in the planning and decision-making of care and services rendered to the resident after the facility became aware of the incidents. Findings: Review of Resident 1's admission Record, indicated he was admitted on [DATE] with diagnoses that include unspecified fall, dementia (impairment in ability to remember, think, or make decisions that interferes with doing everyday activities), muscle weakness, and abnormalities of gait and mobility. Resident 1 was discharged on 11/25/23. During an interview on 12/13/23 at 1:53 PM, Registered Nurse (RN) 1 stated that after a resident fell, a new assessment is needed because of the change in the resident's condition. RN 1 stated, Yes, we should notify appropriate disciplines…

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 bathe or provide shower to one of four sampled residents (Resident 3) for 12 days from 10/5/23 to 10/17/23. This failure may lead to Resident 3's breakdown of skin integrity and accumulation of dirt and bacteria present on the skin's surface, increasing the risk of infection and can negatively impact Resident 3's sense of well-being. Findings: Review of Resident 3's admission Record, indicated Resident 3 was admitted on [DATE] with diagnoses that include ischemic colitis (occurs when blood flow to part of the large intestine is reduced), GI (gastro-intestinal) bleeding, hydronephrosis (swelling of one or both kidneys, and diabetes mellitus Type 2 (a disorder causing blood sugars to be abnormally high). Review of Resident 3's care plan titled, Resident at risk for ADL (activities of daily living) decline, dated 3/23/23 indicated, Interventions/Tasks . Shower/bad bath per schedule and as needed . Review of Resident 3's care plan titled, Resident at risk…

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 develop a comprehensive care plan for a resident that included measurable objectives and specific interventions when: Resident 1 's care plan was not updated when there were documentations of her having altercations with different residents in the facility. This failure has the potential for not meeting the resident's goals of care to meet her highest practicable well-being. FINDINGS: Resident 1 was admitted with the following diagnoses: Senile degeneration of brain (also known as Senile dementia is the mental deterioration (loss of intellectual ability) that is associated with or the characteristics of old age), adult failure to thrive (a state of decline that is multifactorial and may be caused by chronic concurrent diseases and functional impairments.), and dementia with behavioral disturbance among others. During a review of Resident 1 minimum data set (MDS- an assessment tool for nursing home residents) dated 10/1/2020 indicated her brief interview for mental status (BIMS - an assessment tool to assess 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 identify and document, changes in Resident 1 ' s condition when: 1.Resident 1 ' s wound changed to Stage 4. 2.Resident 1 readmitted on [DATE], no skin assessment done. 3.The IDT (Interdisciplinary Team) did not address the changes in condition for Resident 1. These failures had the potential for resident ' s condition not assessed and needs not addressed could result to resident not getting the right treatment and care. Findings: During record review and concurrent interview on 12/6/23, with ADON, nurses progress notes on June 15,2022, indicated, Noc shift endorsed stage 4 on the back, wound nurse notified, gangrene on both heels, discoloration right leg. MD ordered, referral to wound doctor. Confirmed by ADON, No change of condition assessment found, no Skin Assessment found, no IDT meeting found in chart. Review of facility document Nutrition Note, dated 6/24/22, indicated, Weight Variance and Skin /Wound Nutrition Note: declined noted more…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement comprehensive person-centered care plan for one of three residents (Resident 1)when: There was no care plan on 6/10/22 addressing sacral discoloration. There was no care plan on 6/14/22 addressing mid -lower sacrum, coccyx, right and left heel wound . There was no care plan on 6/23/22 addressing the new order for Megesterol acetate (an appetite stimulant). There was no care plan on 7/3/22, when Resident 1 was re-admitted with new Antibiotic order for new Diagnosis of Cellulitis. These failures had the potential to prevent the resident from receiving appropriate and individualized care and services consistent with her needs. Findings: During a record review of facility document, admission Record, dated 7/5/22, indicated, admitted on [DATE] with diagnoses including: Asthma Exacerbation (condition which the airways are inflamed and produces extra mucus making it difficult to breathe), Atrial Fibrillation (irregular heartbeat)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow physician ' s order to obtain weight weekly on admission, and failed to follow facility policy and procedure, as evidenced by no documented weight on day of admission, 3/11/22, week of 3/30/23 and 4/6/23. No Monthly weights for April and May 2022. This failure had the potential for changes in condition not being assessed and identified, resulting in Resident 1 weight loss. Findings: Review of facility document, Order Summary Report, Physician: MD1, dated 3/1/22-6/1/22, indicated, admission: Weekly Weight x 4 weeks, then reevaluate one time a day every Wed for 4 weeks. During an interview on 12/6/23 at 1:50 Pm with MO, ADON 2, stated, Weights are taken on day of admission, then one week after, then weekly x 4, taken on Sundays and Mondays, for the first month. Then every month and per MD ' s order. During a review of facility document, Weights and Vitals Summary, indicated, 3 /16/22 - 107.8. lbs (standing scale), 3/23/22 110 lbs (Standing),…

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 demonstrate that they developed, maintained and implemented a training program for four out of four sampled clinical staff (registered nurse [RN] 1, licensed vocational nurse [LVN] 1, certified nursing assistant [CNA] 1, and restorative nurse assistant [RNA] 1) when the facility could not produce documentation of orientation or competency documentation specific to the facility or resident care population for these four sampled staff. This failure has the potential to result in untrained staff that puts residents ' safety at risk. Findings: During an interview on 11/17/23 at 12:03 PM with the Director of Staff Development (DSD), a request was made for the employee files of RN 1, CNA 1, LVN 1, and RNA 1. A specific request for their licensure and documentation of orientation or competency training was made; the DSD verbalized understanding of the request. During an interview on 11/16/23 at 2:14 PM with CNA 1, CNA 1 states no when asked if the facility ever provided them with any type of orientation or on-boarding training.…

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 prompt resolution of resident council grievances when two out of two sampled grievances lacked pertinent dates or conclusions/outcomes necessary to demonstrate that grievances are processed effectively, and residents are apprised of progress towards resolution. This failure has the potential for resident council recommendations to not be considered or grievances to go unresolved. Findings: A review of the policy titled Resident Council, undated, indicated that A Resident Council Response Form will be utilized to track issues and their resolution. A review of the policy titled Grievances/Complaints, Filing (undated), provided on 11/27/23 at 10:51 AM, the policy indicated that all grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to in writing including rationale for response. In addition, the policy indicated that upon receipt of a grievance and or complaint, the Grievance…

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 care for resident's need (Resident 2), by not reporting or notifying the physician during change of condition when Resident 1 complained of chest pain and severe abdominal pain. This failure resulted in resident not properly assessed by the physician and not given the right medication and treatment. Findings: Resident 2 was admitted to the facility on [DATE] with diagnoses including Supraventricular Tachycardia (irregular fast heartbeat). The physician's progress note dated 4/15/23 indicated Resident 2 was a Full Code. During concurrent interview and record review on 11/16/23 at 4:22PM with LVN 2, RN 2, the Nursing Progress notes dated 4/14/2023 at 9:10PM, and the Medication Administration Record (MAR) dated 4/14/2023 at 9:11PM were reviewed. The Nursing Progress notes indicated patient c/o(complained of) chest pain, patient refusing to go to hospital, Pain medication administered. The MAR indicated Tramadol Hcl tablet 50mg give 1 tablet by mouth…

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 prompt resolution of grievances when two out of two sampled resident grievances lacked pertinent dates or conclusions/outcomes necessary to demonstrate that grievances are processed effectively, and residents are apprised of progress towards resolution. This failure has the potential to result in a residents ' voiced grievances not being heard or resolved. Findings: A review of the policy titled Grievances/Complaints, Filing (undated), provided on 11/27/23 at 10:51 AM, the policy indicated that all grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to in writing including rationale for response. In addition, the policy indicated that upon receipt of a grievance and or complaint, the Grievance Officer will review and investigate the allegations and submit a written report of such finding to the Administrator within five (5) working days of receiving the grievance and/or…

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

Based on interview and record review, the facility failed to ensure licensed nurses have the specific competencies and skills necessary to care for Residents needs (Resident 2) by not taking or reportingto the physician the baseline vital signs during a change of resident's condition. This failure resulted to not meeting Resident 2's nursing needs and goals to attain the highest practicable well being. Findings: Record review indicated that on 4/14/2023 resident 2 complained of chest pain. There was no documented evidence that vital signs (Blood pressure, Temperature, Pulse, Respiration) were taken and reported to the physician. On 4/27/2023 Resident 2 complained of severe abdominal pain. There were no vital signs taken nor recorded. During a concurrent interview and record review on 11/16/2023 at 4:22PM, with LVN 2, staff claimed that on 4/14/2023, Resident 2 had chest pain and refused to go to the hospital. LVN 2 indicated that she notified FNP 1 but did not document, no assessment was made, no vital signs was taken. The Nursing Progress Notes 4/27/2023 at 8:41AM 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 observation, interview and record review, the facility failed to ensure that one out of three sampled residents (Resident 1) was free of any significant medication errors when Registered Nurse (RN) 1 crushed an extended-release medication, Metoprolol (a blood pressure lowering medication made to release slowly over time). This failure had the potential to result in Resident 1 receiving a higher dose of a blood pressure medication at one time, increasing the risk for side effects or hypotensive symptoms (effects due to a quick drop in blood pressure). Findings: A review of Resident 1 ' s face sheet (summary of resident ' s demographic and admitting information), provided on 11/14/23 at 2:05 PM indicated, Resident 1 was admitted in the Fall of 2023 with multiple diagnoses, including: palliative care (specialized care to provide relief of symptoms from a serious illness), essential hypertension (high blood pressure of unknown cause), Alzheimer ' s (a brain disorder that slowly impairs memory and thinking skills), and atrial fibrillation (an irregular heart rhythm that begins…

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 three sampled residents (Resident 2) was free from verbal abuse when Registered Nurse (RN) 3 told him Get out of my face twice. This failure resulted in Resident 2 stating I still don't feel safe here . during an observation and interview by the surveyor. Findings: Review of Resident 2's clinical record, Resident 2 was admitted on [DATE] with diagnoses including Obstructive Reflux Uropathy (flow of urine is blocked), Spinal Stenosis (narrowing of the spine), Functional Quadriplegia (complete inability to move). Review of Resident 2's Minimum Data Set (MDS, an assessment tool) dated 7/18/23, indicated a Brief Interview for Mental Status (BIMS, a cognitive assessment tool) score of 15. Which means intact cognitive response. Review of summary of investigation, dated 9/22/23 indicated RN 3 came into his room at the night of 09/12/2023 acting agitated and frustrated with him saying, what are you ratting on CNA 4 for? and You…

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 the result of the abuse investigation to the California Department of Public Health (CDPH) within 5 working days in accordance with Federal requirements for one of three sampled residents (Resident 2). The alleged abuse incident for Resident 2 occurred on 9/12/23 and the result of facility investigation is not complete during the State Agency investigation visit on 9/21/23. The facility's failure to report abuse according to the required time frame had the potential to delay the identification and implementation of appropriate corrective actions and may place the residents at risk for abuse. Findings: Review of Resident 2's clinical record, Resident 2 was admitted on [DATE] with diagnoses including Obstructive Reflux Uropathy (Flow of urine is blocked), Spinal Stenosis (Narrowing of the spine), Functional Quadriplegia (complete inability to move). During an interview on 9/21/23, at 3:15 PM, the Administrator, stated we are in the process 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 develop care plans for two of three sampled residents (Resident 1 and Resident 2) when: 1. There was no care plan developed to address alleged incident of staff verbal abuse to Resident 2 on 9/12/23. 2. There was no care plan developed to address the fall incident on 7/7/23 for Resident 1. This failure resulted to Resident 1's safety needs not being met and Resident 2's psychosocial needs not being met. Findings: Review of Resident 2's clinical record, Resident 2 was admitted on [DATE] with diagnoses including Obstructive Reflux Uropathy (flow of urine is blocked), Spinal Stenosis (narrowing of the spine), Functional Quadriplegia (complete inability to move). Review of Resident 2's clinical record was conducted on 9/22/23 at 4:50 PM with Registered Nurse 2 (RN 2). The records did not contain evidence that a care plan to address the staff verbal abuse on 9/12/23. During a concurrent interview with RN 2, RN 2 confirmed no care plan was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure each resident receives adequate supervision to prevent accidents, for one of three residents (Resident 1) when they failed to provide the appropriate level of assistance while transferring. This failure resulted in Resident 1 sustaining an injury to her left forehead, with bruising around her left eye area, from falling forward, while a Certified Nursing Assistant (CNA) was toileting the resident on 7/7/23. Findings: Review of Resident 1's clinical record indicated Resident 1 was admitted on [DATE] with diagnoses including end-stage renal disease with hemodialysis (kidney failure needing dialysis), Type II diabetes mellitus (high levels of sugar in the blood) and left-sided weakness related to cerebrovascular accident (stroke causing left sided weakness). A record review showed the admission assessment was done on 7/6/23. admission assessment lists Resident 1's Transferring status as 1-person assist. A record review of the 5-day Minimum Data…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure safe medication storage and distribution practice when: 1. Three of four medication carts (2 [NAME] Team 1, 1 [NAME] Team 2, 2 East Team 1) had loose tablets in the drawers. 2. One of two medication room refrigerators (1 East) had unlabeled medications stored. 3. Four of four medication carts (1 [NAME] Team 1, 2 [NAME] Team 1, 2 East Team 1, 1 [NAME] Team 2), had out of date medications stored. 4. Two of four medication carts (1 [NAME] Team 1, 2 East Team 1) had medications with unreadable label stored. 5. One of four medication carts (1 [NAME] Team 1) had medication labeled refrigerate stored. This failure had the potential for resident to receive wrong medications, contaminated medication, and/or ineffective medication. Findings: During a concurrent observation and interview, on 6/22/21 at 4:00 pm with RN 2, to review 1 [NAME] Team 1 Medication Cart, observed Resident 67's Xalatan (prescription medication for the treatment of high…

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.

2b. Based on interview and record review the facility failed to implement its plan of action to correct the identified deficiencies when: 1. Result of the audit logs for baseline care plan (BCP), wound summary, psychotropic medication were not reviewed as indicated in the plan of correction (POC) dated 9/20/21. 2. In-services were not completed as indicated in the POC dated 9/20/21. The facility failure may result in a repeated regulatory noncompliance which had the potential for residents not receive necessary care and services. Findings: 1a. During an interview on 9/23/21, at 3:05 PM, the Medical Record Director (MRD)stated, I do the audit for the baseline care plan daily and bring them to the Director of Nursing (DON). During an interview on 9/23/21, at 3:10 PM, DON stated, I do not have a documented weekly audit. I didn't know I have to do that. Review of the facility F655 BCP POC, dated 9/20/21 indicated, .3 .Medical Records (MR) will complete a weekly audit of admission and readmissions BCP and review it with the DON . b. During an interview on 9/23/21, at 2:20 PM, DON 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, facility failed to ensure psychotropic medication is used to treat a specific diagnosis and documented condition for one of three sampled residents, (Resident 102) when: a. Risperdal (an antipsychotic) was indicated for dementia (decline in memory or other thinking skills); b. Consent was not obtained for use of Risperdal; c. There is no specific target behavior monitoring for use of Risperdal. Failure to obtain consent, identify and monitor specific behavior manifestation for the use of psychotropic medication had the potential to put the residents at risk of receiving unnecessary medications that could result in serious harm. Definition: Antipsychotic are drugs used to control the symptoms (a physical or mental feature indicating a disease condition) of schizophrenia (a severe mental illness that may change the way a person think, speak, and behave). Findings: Resident 102 was admitted on [DATE], with diagnoses including dementia (decline in memory or other…

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 infection control and prevention program when: 1.a Registered Nurse (RN) 3 brought out a cup from Resident 375's room which was on contact precautions (infection control and prevention measures used for diseases caused by microorganisms that may be spread easily by contact with the patient's intact skin or with contaminated environmental surfaces). 1.b. Physical Therapy Assistant (PTA) did not: (a) wear appropropriate personal protective equipment (PPE) prior to entering Resident 375's room (b) did not perform hand hygiene after exiting Resident 375's room. 2.a. Licensed Vocational Nurse (LVN) 4 did not perform hand hygiene during dressing changes on 1 of twenty-eight sampled resident (Resident 79). 2.b Certified Nurse Assistant (CNA)3 did not perform hand hygiene [wash hands with soap and water or use an alcohol based hand rub (ABHR)] after handing dirty linen, in between, and after the care of two residents (Resident 111 and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to complete a Baseline Care Plan (BCP) for one of 42 sampled residents (Resident 276) when there was no evidence of documentation of a completed BCP. A BCP includes minimum healthcare information necessary to properly care for each resident immediately upon their admission, which would address resident-specific health and safety concerns to prevent decline, injury, such as elopement or fall risk, and would identify needs for supervision, behavioral interventions, and assistance with activities of daily living, as necessary. This deficient practice had the potential to result in inadequate care and services rendered to the resident. Findings: Resident 276 was admitted on [DATE], with diagnoses including osteoarthritis (pain and swelling on the joints) and pneumonitis (inflammation [swelling] of the lungs). During the initial tour on 6/22/21, at 9:40 AM, Resident 276 was observed grimacing while repositioning himself in the wheelchair. 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 submit an application for Change of Ownership (CHOW) to the department. This facility failed to meet the state law (Title 22, 72201 (2)) requirement. Findings: During an interview with the Administrator on 6/22/21, at 9:45 AM, he explained that they took over the facility on 4/8/21. The name of new owner is (name redacted). He acknowledged there is no application filed for the CHOW. During an interview with the Administrator on 6/22/21, at 12 PM, he stated that the company lawyer is calling the Department regarding the CHOW application. During an observation on 6/24/21, the license posted in the facility consumer board indicated license under the name of the previous owner. The California Code of Regulations (CCR) Title 22: Social Security , Division 5, Chapter 3, Article 2, indicated Application required .(2) Change of Ownership .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility has no valid contract to provide onsite hospice care. This facility failure has the potential to negatively impact the provision of care for Resident 30. Definition: Hospice care means a comprehensive set of services . identified and coordinated by an interdisciplinary group (IDG) to provide for the physical, psychosocial, spiritual, and emotional needs of a terminally ill patient and/or family members, as delineated in a specific patient plan of care .these services are provided by a Medicare-certified hospice . Findings: Resident 30 was admitted on [DATE] under the care of (Hospice Care agency), diagnoses include heart failure (when the heart does not pump as strong as it should), chronic obstructive pulmonary disease (COPD,a group of lung diseases that block airflow and make it difficult to breathe), and cerebral infarction (stroke). During an interview with the Administrator on 6/23/21, at 9 AM, he stated, It should be in one of these binders. I will bring…

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 safe, functional, and clean environment for residents. 1. Beauty salon door was not kept clean. 2. Uncleaned equipment and residents' personal items were stored in the residents' shower room. 3. The eye wash station located in the laundry room was not cleaned. These failures had the potential to not provide a clean and safe living conditions for the residents. 1. During an initial tour observation on 6/22/21 at 8:53 AM, the beauty salon located at the first floor had a sign at the door indicating, In Use, and the entrance door was closed. The door had fixed horizontal slats on the lower panel that had significant accumulation of dust and gray-like fuzzy material. During an interview on 6/22/21 at 8:54 AM, with Housekeeping Aide (HKA) 1, HKA 1 acknowledged the observations and stated, .it's dirty . should be dusted off and cleaned . HKA 1 stated his responsibility were to clean residents' room, and called in another staff who was in the hallway. During an interview on 6/22/21 at 8:55 AM, with HKA 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.