Eureka Rehabilitation & Wellness Center, LP

Based on observation, interview, and record review, the facility failed to ensure medications were stored safety and within accepted professional standards of practice for a census of 87 residents when:Loose pills were found in a medication cart,Medications were found without open dates, and;Used insulin pens were found comingled in the same drawer.These findings had the potential to result in medication errors, decreased medication therapy, and harm to the residents of the facility. During a concurrent interview and C wing medication cart inspection on 1/28/26 at 1:14 p.m., with the Director of Nursing (DON), the DON confirmed the following: 10 loose pills were found in the medication cart. The DON stated loose pills could potentially be given mistakenly to residents or be taken by staff.Six medications were found without open dates. The DON stated open dates were necessary to ensure that medications were not outdated. The DON further stated that if these medications were administered to residents, they could potentially cause adverse effects or be less therapeutic.Six used insulin…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 garbage was properly contained for a census of 87 residents when one out of two dumpsters were observed with open lids, was overflowing with trash, and the area around it was littered with garbage.This failure had the potential to expose the facility environment to odors, insects, pests, and disease, which could have caused harm to the residents. During a concurrent observation and interview on 1/26/26 at 10:40 a.m. with the Dietary Supervisor (DS), one of the two facility dumpsters was left open with plastic bags filled with garbage piled above the top of the dumpster. The dumpster was observed without the lids on to provide closure to the dumpster. One bag of garbage and a box was on the ground next to the dumpster. The DS confirmed the dumpster was overflowing and was too full to close the lids. The DS confirmed there was garbage in the surrounding area outside of the dumpster. The DS further stated, The lids are supposed to be closed to keep the pests and critters out.During an interview on 1/29/26…

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

Based on observation, interview, and record review, the facility failed to maintain a safe and functional environment for one of 21 sampled residents (Resident 70) when Resident 70's light was not in working condition. This failure had the potential to increase Resident 70's risk for accidents, feelings of frustration and lack of independence. A review of Resident 70's admission record indicated she was admitted to the facility in July, 2025, with medical diagnosis which included spinal stenosis (a narrowing of the spinal canal which puts pressure on the spinal cord and nerves), strabismus (eyes are misaligned and do not point in the same direction) and vascular dementia (when damaged blood vessels reduce blood flow and oxygen to the brain, impairing thinking, memory, and function).A review of a Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 1/07/26, indicated Resident 70 had moderate cognitive (relating to or involving the processes of thinking and reasoning) impairment, and required partial to moderate assistance (helper does less than half the effort)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 nursing services that met professional standards of quality for three residents (Resident 1, Resident 2, Resident 3) out of a sampled seven residents when licensed nurses did not:1. Initiate a care plan that included a recent occurrence of resident-to-resident abuse for Resident 1 and Resident 2; and,2. Conduct 72-hour monitoring following Resident 3's fall.These failures had the potential to place Resident 1, Resident 2, and Resident 3 at risk for serious harm, health deterioration and a loss of quality of life.1.A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with Alzheimer's Disease (a disease characterized by progressive decline in mental abilities).A review of Resident 1's care plans indicated the following:- On 10/25/24 a care plan was initiated and indicated Resident 1 had the potential to be physically aggressive related to dementia (a decline in memory, reasoning, thinking 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 observation, interview, and record review, the facility failed to accurately assess a resident's fall risk status and ensure a care plan was person-centered for one resident (Resident 1) of four sampled residents when Resident 1 was admitted to the facility with a history of falls These failures decreased the facility's ability to supervise and prevent Resident 1's fall on 5/24/25 which resulted in a right nondisplaced (not shifted out of place) distal radius (bone that is near the wrist of your lower arm) fracture (a break) to the right arm, limiting use of her dominant hand. Findings: A review of Resident 1's hospital History and Physical , dated 4/7/25 at 4:30 p.m., indicated Resident 1 fell at home and sustained a right distal femur (thigh bone) fracture. A review of Resident 1's admission record indicated Resident 1 was admitted from a local hospital on 4/14/25 for orthopedic (musculoskeletal) aftercare for a fracture of the right femur and a fracture around an internal prosthetic (artificial) knee joint. A review of Resident 1's Fall Risk Evaluation dated 4/14/25 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 facility policy review, the facility failed to ensure food items were labeled and dated. This had the potential to affect all residents receiving meals from the dietary department. Findings included: A facility policy titled, Food Storage and Handling, revised 02/29/2024, revealed the sections titled 6. Fresh Fruit Storage and 9. Fresh Vegetable Storage specified, Label and date all food items. An initial tour of the kitchen was conducted with the Dietary Manager (DM) on 02/17/2025 at 8:36 AM. The following items were observed in the reach-in refrigerator with no labels to identify what the items were or the open or use-by dates: a quart-sized bag of sliced carrots, a quart-sized bag of vegetable patties, and a covered bowl of fruit. During an interview on 02/17/2025 at 8:36 AM, DM confirmed the food items should have been dated and labeled. A follow-up tour of the kitchen was conducted with the DM on 02/19/2025 at 10:30 AM. During this tour, a gallon-sized bag of Salisbury steaks was in the reach-in freezer with no label identifying what 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 and interview, the facility failed to ensure a Level I Preadmission Screening and Resident Review (PASRR) accurately reflected the presence of diagnosed mental disorders for 1 (Resident #53) of 6 sampled residents reviewed for PASRR requirements. Findings included: An admission Record revealed the facility admitted Resident #53 on 04/22/2022. According to the admission Record, the resident had admission diagnoses that included depression and post-traumatic stress disorder (PTSD), both with an onset date of 04/27/2022. Resident #53's Preadmission Screening and Resident Review (PASRR) Level I Screening, completed by the Medical Records Director (MRD) on 05/13/2022, indicated the Screening Type was an Initial Preadmission Screening (PAS). Section III - Serious Mental Illness Screen, question 10 was answered no to indicate the resident did not have a diagnosed mental disorder such as depression, anxiety, panic, schizophrenia/schizoaffective disorder, psychotic, delusional, and/or mood disorder. The screening did not reflect the presence of Resident #53's diagnoses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure there were adequate staff when: 1.Four out of four residents (Residents 2, 3, 4 and 5) complained the facility was short staffed. 2. Six out of six staff reported the facility was short staffed. 3. Based on the census (official periodic count of a population) and Direct Care Service Hours Per Patient Day (DHPPD, the minimum number of actual nursing hours performed by nursing staff per patient day), the facility did not meet the actual DHPPD for 8 out of 10 days from 4/21/24 up to 4/30/24 on these dates: 4/21/24 at 2.68, 4/22/24 at 2.63, 4/23/24 at 3.30, 4/25/24 at 3.43, 4/26/24 at 3.08, 4/27/24 at 3.35, 4/28/24 at 2.93, 4/29/24 at 2.99. These failures resulted in 1A. Resident 2 stated staff was always in a rush to complete their task and feeling unsafe that nobody could come to help her if she needed help in case of a medical emergency. 1B. Resident 3 feeling frustrated she had to wait for up to an hour for staff to answer their call light.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure licensed nurses have the competencies necessary in providing care for the residents when: 1.Licensed Nurses (LNs) were not accurately documenting the skin impairment and its location for one out of two sampled residents (Resident 1). 2. LNs failed to recognize signs and symptoms of Urinary Tract Infection (UTI, a bacterial infection of the bladder and associated structures) and Sepsis (your body's extreme reaction to an infection) for one out of 2 sampled residents (Resident 1). These failures: 1A. resulted to inaccurate documentation as to the exact location and status of Resident 1 ' s pressure injury (PI, breakdown of skin integrity due to pressure). 2B. resulted to Resident 1 ' s fall on 4/25/24 causing an acute comminuted right femoral intertrochanteric fracture (a comminuted fracture occurs when your bone breaks into more than three pieces, intertrochanteric fracture is when a hip breaks between the bumpy parts at the top of the thigh…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure one out of two sampled residents (Resident 1) received his showers twice a week as scheduled every Sundays and Wednesday. This failure reduced the facility ' s potential to mitigate Resident 1 ' s skin breakdown and reduced the potential for skin infection. Findings: A review of Resident 1 ' s face sheet (demographics) indicated Resident 1 was admitted on [DATE] with diagnoses which included Muscle Weakness, and Bipolar disorder (a mental health condition that causes extreme mood swings). A review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment tool) dated 4/9/24, indicated Resident 1 had a severely impaired cognition. Resident 1 ' s MDS dated [DATE] indicated he needed substantial assistance from staff during dressing and personal hygiene, but was dependent on staff during toileting, bathing or showering and putting on or taking off footwear. Resident 1 was incontinent (no control) of bowel function (eliminate feces from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to: 1.recognize signs and symptoms of Urinary Tract Infection (UTI, a bacterial infection of the bladder and associated structures) and Sepsis (your body's extreme reaction to an infection) for one out of 2 sampled residents (Resident 1). This failure resulted to Resident 1 to fall on 4/25/24 which caused: A.skin tear(traumatic wounds that may result from a variety of mechanical forces such as shearing - a horizontal force that causes the bony prominence to move across the tissue as the skin is held in place, or frictional forces- the rubbing of one body against another , including blunt trauma, falls, poor handling, equipment injury) on his right elbow measuring 6.4 centimeters (cm, a measure of length) and; B.an acute comminuted right femoral intertrochanteric fracture (a comminuted fracture occurs when your bone breaks into more than three pieces, intertrochanteric fracture is when a hip breaks between the bumpy parts at the top of the thigh bone).;…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 report an allegation of abuse, in accordance with facility policy and procedure and with state law, for one resident (Resident 1), when the facility did not notify the appropriate agencies such as California Department of Public Health (CDPH), Local law enforcement, and Ombudsman of a potential allegation of abuse, within the required timeframe. This failure had the potential for the alleged abuse to continue and did not allow the appropriate agencies to investigate the allegations. Findings: A review of Resident 1's face sheet (admission record) indicated Resident 1 was a [AGE] year-old female admitted to the facility on [DATE], with a medical diagnosis that included: Chronic obstructive pulmonary disease (COPD, a lung disease that makes it hard to breathe), metabolic encephalopathy (an alteration in consciousness due to brain dysfunction), Wernicke's encephalopathy (a degenerative brain disorder caused by the lack of vitamin B1),…

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

Based on observations, interviews and records review, the facility failed to follow the lunch menu on 6/6/22 when margarine was not provided with dinner rolls for all residents in the facility. This failure could lead to a decline in the nutritional status of residents in the facility. Findings: During an interview on 6/6/22 at 12:20, Resident 16 complained that the food was tasteless. No salt, pepper or garlic. Look I have a roll and no butter. It is like they don't care what they serve us. During an interview on 6/6/22 at 12:26, Resident 40 complained that his roll had no butter. During an interview on 6/7/22 at 2:28 p.m., the Regional Dietary Manager, when asked what diet order did not receive margarine with the dinner roll served during lunch on 6/6/22, stated everyone should have margarine except for regular, small portion diets. During an interview on 6/8/22 at 8:30 a.m., the Dietary Services Manager when told the survey team observed and received resident reports of no butter for their dinner roll at lunch time on 6/6/22, stated it was an oversight. During a review of the…

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

Based on observation, interview and record reviews, the facility failed to prepare food to conserve flavor and palatability (tastiness) for four of 31 residents (Resident 62, Resident 16, Resident 123, and Resident 19) observed during lunch from 6/6/22 to 6/8/22. This failure could lead to weight loss among residents not consuming their food. Findings: During initial tour and interview on 6/6/22 at 09:32 a.m., Resident 62 stated They do not serve the right food for a diabetic. No fresh fruit or vegetables. They don't know what to give me .they might as well give me Stouffer's. During an interview on 6/6/22 at 12:20 p.m., Resident 16 complained the food was tasteless. No salt, pepper or garlic. Look I have a roll and no butter. It is like they don't care what they serve us. During an observation and interview on 6/6/22 at 12:55 p.m., Resident 123 ate all her food but when asked how her food was, she raised her brows, shrugged, and stated it did not taste good. During an interview on 6/7/22 at 12:30 p.m., Resident 16 stated, the only thing I can eat at this facility is the hamburger.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Quality Assurance and Performance Improvement (QAPI) committee failed to identify and improve on three deficient practices found during the recertification survey process. This failure resulted in lack of symptoms monitoring for psychotropic medications, responsible parties (RP) were not notified that residents were refusing their showers, and responsible parties were not notified of changes in residents' condition. Findings: During an interview on 6/10/22 at 10:32 a.m., when asked if the QAPI committee had been working to improve on notifications to RP regarding refusals of showers or changes in condition, DON stated the committee had not. DON also stated the QAPI committee had not identified issues with behavior or symptoms monitoring related to psychotropic medications. When asked how the committee finds issues for the committee to work on, Administrator stated they talked about issues brought to the committee by staff or an issue might come up on an audit. Review of facility policy Quality Assurance and Performance Improvement…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interim director of staff development (DSD) failed to maintain a system to ensure all staff with access to vulnerable residents were trained in abuse prevention and reporting. This failure could potentially result in harm to residents. Findings: On 6/6/22 the Department initiated a recertification survey that included the investigations into four reports of resident abuse allegations and two reports of resident-to-resident incidents. During an interview and concurrent record review on 6/10/22 at 8:44 a.m., IP Nurse stated the facility did training on abuse prevention and reporting every six months, at hire, and as needed, such as when a resident-to-resident incident occurred. Requested sign-in sheets for abuse inservices for the past year. Inservice sign-in sheets provided, dated 2/16/21, 6/4/21, 3/2/22, and 5/13/22, with a gap of nine months between 6/4/21 and 3/2/22 noted. Review of sign-in sheets revealed the inservice on 2/16/21 had 34 staff in attendance, 6/4/21 had 37 staff in attendance, 3/2/22 had seven staff in attendance, 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, interviews and record reviews, the facility failed to provide two out of 19 sampled residents (Resident 22 and Resident 42) scheduled weekly showers who depended on staff to assist. This failure to provide the necessary care resulted in residents looking unkempt and had the potential for residents having body odor, dry broken skin and infection. Findings: Resident 22 was an [AGE] year old resident with a diagnosis of Generalized Weakness and Adult Failure to Thrive (AFT, a decline seen in older adult resulting in poor nutrition, inactivity, depression and decreasing functional ability.) Resident 42 was an [AGE] year old resident with a diagnosis of Dementia and muscle weakness. During an interview and concurrent shower sheets record review on 6/8/22 at 3:30 p.m., Infection Preventionist/ Director of Staff Development (IP /DSD) stated Resident 42 should be receiving eight showers in a month. IP/DSD verified Resident 42 received two showers for January 2022, one shower for February 2022, four…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and records review, the facility failed to act on the facility pharmacist's recommendation to add monitors for manifested behavior and side effects of a psychotropic (substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) medication for three of five residents sampled for unnecessary medication review (Resident 67, 19, and 38). This failure had the potential to lead to the facility staff not knowing if the medication was effective in reducing symptoms of depression, psychosis, or producing undesirable side effects that would then necessitate a discontinuation or a change in medication. Findings: 1. During a review of records on 6/6/22 at 11:04 a.m., Resident 67's electronic record indicated she was admitted to the facility on [DATE]. Further review of records indicated Resident 67 was on Wellbutrin (an antidepressant) SR (sustained release) 150 mg (a unit of mass or weight equal to one thousandth of a gram) tablet once a day 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 observation, interview and record review the facility failed to ensure that all drugs and biologicals used in the facility were labeled in accordance with professional standards and the facility policy. This failure put residents at risk of receiving medications that were expired and potentially ineffective and unsafe for use. Findings: During an observation and concurrent interview on [DATE] at 10:30 a.m. while inspecting the Medication Room of Unit A with LVN H, the refrigerator contained Novalog expired 5/22, Hep B vaccine expired [DATE]. LVN H stated, the Novalog and Heb B vaccine are expired. She took them and gave them to the Director of Nursing. During an observation and concurrent interview on [DATE] at 3:00 p.m. with the Director of Nursing (DON) in Unit B while inspecting the medication cart, the medication cart contained Levimir with no open date, Novalog with no opened date and Albuterol opened [DATE]. The DON stated, the Levimir and Novalog should have an opened date and expiration date 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 records review, the facility failed to offer or ensure availability of food of similar nutritive value to three randomly selected residents (Resident 20, Resident 123, and Resident 124) and four of 19 sampled residents (Resident 67, Resident 125, Resident 17, and Resident 19) when Resident 20, Resident 19, and Resident 17 were not offered food from the alternate menu, and Resident 124, Resident 67, Resident 123, and Resident 125 were not provided the list of alternate food menu they can choose from. This failure had the potential to result to inadequate intake and nutrition for residents in the facility. Findings: During dining observation on 6/6/22, at 12:55 p.m., Resident 20 ate a small portion of her lunch and left to propel herself out of her room. Outside her room a Certified Nursing Assistant (CNA) asked Resident 20 what she wanted, and both jokingly played a guessing game with the CNA guessing what the resident wanted. When the CNA stated the resident wanted a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to follow infection control practices when 1. Handheld thermometer and pens where not sanitized in between use for screening staff/visitors. 2.There were no hand sanitizers readily accessible for staff to use in 14 out of 14 rooms in Memory Lane unit 3. Hand hygiene (a general term that applies to hand washing, antiseptic hand wash, and alcohol-based hand rub) were not provided for nine out of 19 sampled residents ( Residents 14, 22, 25, 27, 29, 43, 55, 57 and 61) prior to meals. 4. There were missing/broken tiles in two out of 14 rooms in Memory Lane unit ( room [ROOM NUMBER] and #20 ) and laundry room. This failure had the potential to 1. transmit infection to resident from staff and or visitors 2. prohibits adequate cleaning and sanitizing of floors. Findings: During an observation on 6/6/22 at 8:05 a.m., 6/7/22 at 8:00 a.m. and 6/8/22 at 9:00 a.m., there was no assigned staff to sanitize or give instructions on how to sanitize handheld…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 it's policy and procedure and manufacture's recommendations to maintain patient care equipment when quality controls for blood glucose monitors were not performed daily per facility policy. This failure has the potential to give incorrect blood sugar readings for residents which staff rely on to give appropriate medication to the residents. On [DATE] at 4:00 p.m. during an inspection of the medicine cart on Unit A with the Director of Nursing (DON), the Accucheck solution was found to be expired, dated [DATE]. The DON took the Accucheck solution out of the cart and replaced it with a new solution. She stated, This should have been replaced. During a review of the Quality Control Record Checks for Blood Glucose Monitoring on [DATE] Unit A, dated [DATE] thru [DATE] Days, No Quality Control Check was done Unit B, dated [DATE] thru [DATE], missing March's records, 46 Days No Quality Control Check done Unit C, dated [DATE] thru [DATE],…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to involve the responsible party in the care planning process of one of two sampled residents, Resident 173. This potentially resulted in Resident 173 losing weight when the staff caring for her did not know what foods she liked, what texture she needed, or her level of assistance needed with eating. Findings: During an interview on 8/31/21 at 12:55 p.m., Responsible Party (RP) 2 stated that after Resident 173 was transferred from the hospital to the facility, RP 2 drove to the facility (four hours) to participate in Resident 173's admission process. RP 2 stated that when she arrived at the facility, no one greeted her or showed her around, and the business office staff told RP 2 that they did not have anything ready for [her]. RP 2 stated a telephone care conference was scheduled but no one called her at the scheduled time. RP 2 stated another telephone care conference was scheduled, but then it was canceled. RP 2 stated Physician A called her the day…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and record reviews, the facility failed to notify the Responsible Party (the person designated to make healthcare decisions for someone who has lost capacity to make decisions for themselves; in some cases the RP is an agency, like the Public Guardian) and the physician in three out of 19 sampled residents (Resident 22, Resident 42 and Resident 173) of significant changes in their health status. This failure had the potential to result in a delay in treatment, RP's not being involved in the resident's care and RP's feeling upset and very frustrated. Findings: 1. Resident 22 was an [AGE] year old resident with a diagnosis of Generalized Weakness and Adult Failure to Thrive (AFT, a decline seen in older adult resulting in poor nutrition, inactivity, depression and decreasing functional ability.) Resident 22 was under the Public Guardian conservatorship (a guardian was appointed by a judge to manage his financial and medical care.) During an interview and Interdisciplinary Team…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of 74 residents (Resident 18) was free from physical abuse when a staff hit Resident 18 in the chest. This failure resulted in Resident 18 being subject to physical abuse. Findings: A review of Resident 18's Facesheet indicated he was admitted to the facility on [DATE] and had diagnosis including encephalopathy (a disease that alters brain function), alcohol dependency, and antisocial personality disorder. A review of Form SOC 341, Report of Suspected Dependent Adult/Elder Abuse, dated 11 /21 /21, submitted by the facility to the Department, informed that a Certified Nursing Assistant (CNA) hit Resident 18. The Form SOC 341 indicated that on 11/21/21, at around 7 a.m., Resident 18 reported to IP Nurse that CNA P had hit him on the chest. Resident 18 reported: She [CNA P] packs a good punch. The Form SOC 341 indicated that CNA P admitted she hit Resident 18 on the chest with the back of her hand because Resident 18 was insulting staff by…

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

Based on interview and record review, the facility failed to report the results of its investigation of one allegation of abuse to the California Department of Public Health (the Department) within five working days of the incident. This failure prevented the Department from being informed of the facility's investigation of the abuse allegation. Findings: A review of form SOC 341, Report of Suspected Dependent Adult/Elder Abuse, dated 11/21/21, indicated the facility reported to the Department the suspected abuse of one resident (Resident 18) on 11/21/21. A review of Department records indicated no record of receipt of the facility's investigative report of the above incident. During an interview on 12/1/21, at 1:05 p.m., the Administrator confirmed the facility did not submit to the Department a written report of its investigation of Resident 18's abuse allegation dated 11/21/21, which the facility substantiated. A review of facility policy titled Reporting Abuse, dated January 2014, indicated: The Administrator, or his or her designee, shall provide the appropriate agencies or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to complete accurate assessments for two of 14 sampled residents, Resident 17 and Resident 19. This failure could potentially result in incomplete care plans for Resident 17 and Resident 19. Findings: Resident 17 During an observation on 6/8/22 at 2:54 p.m., Licensed Nurse J changed the dressings on Resident 17's lower legs. Resident 17 had an open wound on her leg just above her left ankle. Review of Resident 17's medical record revealed Resident 17 was admitted on [DATE]. Resident 17's diagnoses included localized edema (swelling caused by excess fluid trapped in the body's tissues), disorder of the skin and subcutaneous (under the skin) tissue, and peripheral vascular disease (PVD, narrowing of blood vessels which reduces blood flow to the limbs) among others. Review of Resident 17's document Wound Assessment and Plan dated 5/5/22, written by the wound specialist, indicated Resident 17 had a venous wound (open sore caused by problems with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a baseline care plan within 48 hours for one of two sampled residents, Resident 173, who had a history of falls, and failed to provide a copy of Resident 173's baseline care plan to Resident 173's representative. This failure could have potentially resulted in Resident 173 falling when there was no plan in place for staff to keep her safe from falls, and resulted in Resident 173's responsible party, RP 2, feeling upset and very frustrated when she never had the opportunity to discuss Resident 173's care needs with staff and did not know the plan for Resident 173's care. Findings: During an interview on [DATE] at 12:55 p.m., Responsible Party (RP) 2 stated she had cared for Resident 173 for 15 years, but that Resident 173 was transferred from a hospital to the facility's memory care unit due to Resident 173's worsening dementia. RP 2 described how on the day Resident 173 was transferred to the facility from the hospital ([DATE]) RP 2 arrived at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan for use of an antipsychotic medication when one of five residents sampled for unneccessary medications, Resident 19, did not include the target behavior for the medication or any goals related to the target behavior. This failure resulted in an incomplete plan of care for the use of a drug known to cause increased risk of death in elderly people. Findings: During an observation and concurrent interview on 6/6/22 at 12:23 p.m., Resident 19 was sitting up on the side of his bed coloring a coloring sheet with colored pencils. When queried, Resident 19 stated he was doing alright except he had an upset stomach and a headache today. During an observation on 6/7/22 at 10:08 a.m., Resident 19 stopped this surveyor in the hallway and asked to tell his nurse that he wanted something for his stomach because it was hurting. During an interview on 6/7/22 at 2:39 p.m., Licensed Nurse H stated she was monitoring…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff did not complete admission progress notes or document accurate skin assessments for one of two sampled residents, Resident 173. This resulted in an incomplete medical record for Resident 173. Findings: During an interview on [DATE] at 12:55 p.m., Resident 173's responsible party, RP 2, stated that when no one called her for her scheduled telephone care conference, she called the facility and was told Resident 173 had fallen. RP 2 stated that a few days later, Resident 173 was found unresponsive, then her husband got the call that Resident 173 had passed away. RP 2 stated she wanted to know what happened to Resident 173, so she and her family decided to pay for an autopsy. RP 2 stated the autopsy showed Resident 173 had a bruise on her thigh. During an interview on [DATE] at 3:55 p.m., RP 2 stated the autopsy for Resident 173 reported a five-by-seven centimeter yellow, green, purplish superficial healing bruise of the skin surface on the upper left thigh.…

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

Based on observations, interviews and record reviews, the facility failed to promote appropriate use of antibiotics (a medication used to treat bacterial infections) when one out of 19 sampled residents (Resident 35) was prescribed an antibiotic without initiating the McGreer's criteria ( used to retrospectively count true infections) for Urinary Tract Infection (UTI- an infection in any part of the urinary system) and without waiting for Urinalysis (UA, a test of urine used to detect and manage a wide range of disorders), Culture and Sensitivity result (C&S, a culture is a test to find germs, a sensitivity test checks which type of antibiotic will work best to treat an infection.) This failure had the potential to cause antibiotic resistance, severe infections and complications. Findings: During an interview on 6/8/22 at 11:00 a.m., Infection Preventionist/ Director of Staff Development (IP/DSD) verified Resident 35 was prescribed an antibiotic to treat UTI. IP/DSD confirmed resident received the first dose of antibiotic on 6/6/22. IP/DSD and IP consultant verified McGreer'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.