Mayers Memorial Hospital

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement care planned fall prevention interventions (a set of proactive measures designed to minimize the risk of falls in individuals) for 2 of 4 residents sampled for falls who had been identified as high risk for falls (Resident 1 and 2) when: 1. Resident 1's care planned intervention for staff to follow Resident 1 to his room and assist him with toileting or lying down was not followed. 2. Resident 2's care planned intervention to ensure that Resident 2 was wearing non-skid socks or footwear was not followed. These failures resulted in avoidable falls with broken hips for both Resident 1 and 2 which and rehospitalizations for surgical repairs. This had the potential to negatively impact the residents' physical and emotional well-being and subject them to further falls with injuries. Findings: A review of the facility's policy titled, FALLS-SNF (Skilled Nursing Facility) dated 5/22/23, indicated that a fall is an unplanned descent to the floor…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to prevent physical and verbal abuse for two of six sampled residents (Resident 3 and Resident 4) when Certified Nursing Assistant (CNA) A was rough with Resident 3 and CNA H cursed and threw personal care items toward Resident 4. These failures violated Resident's 3 and 4's right to be free from abuse and caused Resident 4 to fear CNA H. These failures and had the potential to subject residents to physical harm, mistreatment and negatively impact their emotional and psychosocial well-being. Findings: Review of the facility ' s policy and procedure titled, Abuse, Resident dated 3/2/2023 indicated that the facility, .ensure that each patient has the right to be free from abuse (verbal, sexual, physical and mental) and The facility prohibits mistreatment . Review of admission records for Resident 3 indicated Resident 3 was admitted to the facility on [DATE], with diagnoses including dementia (loss of memory and ability to make sound decisions), chronic pain…

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 a thorough investigation of an allegation of staff to resident abuse was conducted for one of six sampled residents (Resident 3). This failure had the potential to put all residents of the facility at risk for staff to resident abuse. Findings: Review of a facility policy titled, Abuse, Resident dated 3/2/2023 indicated that, 5. a) The facility will investigate all suspected incidents .i) Obtain written statements by all persons involved while facts are fresh in their minds. Review of a facility policy titled, Guidelines for Conducting Investigation Accidents/Incidents dated 10/8/2019, indicated that, 1. The Licensed Nurse on duty at the time an accident or incident occurs will .a. i. Conduct staff/resident interviews. Review of Resident 3 ' s Annual Minimum Data Set (MDS an assessment tool) dated 1/30/25, reflected that Resident 3 scored 3 out of 15 possible points on a Brief Interview for Mental Status (BIMS, an assessment of memory and decision-making skills), which indicated severely impaired cognition. During…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record reviews, the facility failed to ensure Resident 4 was monitored specifically for any problems resulting from the abuse he experienced when Certified Nursing Assistant (CNA) H was rough with Resident 4 and threw personal care items at him on 1/10/25, when they did not complete change in condition charting (documentation done just after an unexpected incident occurs that had a negative effect on a resident to communicate the resident's condition to other healthcare providers), and alert charting (ongoing documentation of monitoring for 72 hours after an accident, injury, or incident to reassess if any problems occurred over time resulting from the accident, injury, incident), was initiated late. These failures had the potential for staff to not be fully informed and intervene if Resident 4's mental and medical status declined which could result in delays in care and a decline in Resident 4's physical and emotional well-being. Findings: Review of a facility policy titled, Charting and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure their abuse reporting policy was followed for six of 14 residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, and Resident 6) sampled for abuse when: 1. Resident 1 had an altercation with Resident 6 and the follow-up investigation was not sent to California Department of Health (CDPH) as per facility policy. 2. Resident 4 was accused of an altercation with Resident 3 and Resident 5 and the follow-up investigation was not sent to the CDPH as per facility policy. 3. Resident 2's family member (FM) was accused of verbally abusing Resident 2 and the facility did not report the alleged abuse to the CDPH withing 24 hours per facility policy. This failure had the potential to subject residents to mistreatment, neglect or abuse. Findings: 1.A review of the facility's policy and procedure (P&P) titled Abuse, Resident revised 3/2/23, indicated Results of investigation are reported to, with documentation of dates and times, as appropriate .…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to prevent verbal abuse for one of three sampled residents (Resident 1) when Registered Nurse (RN) A yelled and cursed at Resident 1 and told Resident 1 to not use her call light. This mistreatment caused Resident 1 distress and feelings that her needs were not met and had the potential to affect all residents under the care of RN A and negatively impact their quality of life and emotional well-being. Findings: Review of the facility's policy and procedure titled, Abuse, Resident dated 3/23/2023, indicated that the facility .ensure that each patient has the right to be free from abuse (verbal, sexual, physical and mental) and The facility prohibits mistreatment . Review of admission records for Resident 1, indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), Age related cognitive decline (difficulty thinking and making…

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 five of seven sampled residents (Resident 1, 2, 3, 4 and 5) were free from verbal abuse when Certified Nurse Assistant (CNA) 1 verbally abused Residents 1, 2, 3, 4, and 5. This failure had the potential to negatively impact Resident 1, 2, 3, 4, and 5's sense of security, increased loss of dignity, and humiliation and emotional, and psychological well-being. Findings: During a review of Resident 1 ' s clinical record, Resident 1 was admitted to the facility on [DATE] with diagnoses that included dementia (memory loss), anxiety (fear of the unknown), Spinal stenosis (a narrowing of the spinal canal in the lower part of your back), and high blood pressure. The most recent Minimum Data Set (MDS, a standardized resident assessment) dated 3/27/24, indicated, Resident 1 was cognitively intact (able to think and reason). During an interview on 5/24/24, at 9:30 a.m., with Resident 1, Resident 1 stated, I have a hard time sitting up due to pain. CNA 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of two residents (Resident 1 and Resident 2), sampled for unsafe wandering (a random, aimless or repetitive search for an exit that is non-goal-directed), and elopement (a resident leaves the premises or a safe area without the facility's knowledge and supervision) was assessed and monitored for unsafe wandering and elopement. Resident 1 and Resident 2 eloped from the facility and had no wander/elopement risk assessments at the time of their elopements. These failures resulted in Resident 1 eloping from the facility from an unknown exit at an unknown time and being found in the facility ' s parking lot by a staff member who happened to go out to the parking lot. And Resident 2 eloping from the facility and being found by law enforcement at a gas station four-tenths of a mile away, in the middle of the night. Findings: A review of the facility ' s policy titled, Elopement Policy, dated 5/8/24, indicated that the facility must…

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 meet the required daily Registered Nursing (RN) hours for Payroll Based Journaling (PBJ) staffing information submitted to the Centers for Medicare and Medicaid Services (CMS). Failing to meet the required hours the facility did not ensure an adequate level of staff is working at a given time, potentially leading to inadequate care of residents and adverse clinical outcomes. FINDINGS During a concurrent record review and interview on 05/09/24 at 12:33 PM, the Quality Manager (QM) confirmed the required RN coverage was not met for 20 days of the first Federal Quarter of 2024 (The first Federal Fiscal Quarter begins October 1st of the prior year, in this case, October 1st, 2023). The QM stated, It is all here and matches the PBJ report on these dates. We did not have an RN present on the schedule. We do have them in other roles and we encourage them to clock in when they are giving resident care. Referring to the XML template (computer staffing sheet) the QM stated, It is the 7 group (designation) only which…

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 report abuse allegations on 4/8/24 and unknown date for Resident 10 and reported late for Resident 50 and 278 when: 1. One of three sampled residents (Resident 10) was verbally and physically abused. 2. Two of three sampled residents (Resident 50 and 278) were reported late. Findings: 1. During a review of the facility's policy and procedure (P&P) titled, Abuse, Resident, dated 7/15/2022, included the following statement, For all intents and purposes, the word patient(s) refers to all customers receiving health care services in our facilities, including inpatients, outpatients, residents, and clients, the P&P indicated, each patient has the right to be free from abuse (verbal, sexual, physical and mental) including corporal punishment and isolation. Patients must not be subjected to any of the above by anyone, including, but not limited to, facility staff, other patients, consultants, volunteers, and other agencies that service the patient, family…

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 review and revise the Care Plans for two of four sampled residents (Residents 27 and 128) when information about their risk for elopement (leaving the facility without staff's knowledge) and exit alarm devices was not included in their Care Plans. This failure had the potential to put the residents at risk for accidents related to elopement. Refer to F 689. Findings: A review of Resident 27's clinical record indicated they were admitted to the facility on [DATE]. Resident 27's diagnoses included anoxic (lack of oxygen) brain damage and a prior heart attack. Resident 27's BIMS (Brief Interview for Mental Status) score was three, which indicated severe cognitive (intellectual) impairment. A review of Resident 27's physician's orders for May 2024 showed a verbal order entered on 12/9/23 for, Wander guard (a device that emitted an audible alarm when the resident approached an exit) applied to left ankle for safety Change Q (every) 90 days every shift 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 make sure the environment was free of all accident hazards for two of four sampled residents (Residents 27 and 128) when they had orders for Wanderguard ® (a device worn on the body that caused an alarm to sound at exit doors) placement, with no follow-up or monitoring. This failure had the potential to put the residents at risk for accidents related to elopement (leaving the facility without staff's knowledge). Refer to F 657. Findings: A review of Resident 27's clinical record indicated they were admitted to the facility on [DATE]. Resident 27's diagnoses included anoxic (lack of oxygen) brain damage and a prior heart attack. Resident 27's BIMS (Brief Interview for Mental Status) score was three, which indicated severe cognitive (intellectual) impairment. A review of Resident 27's physician's orders for May 2024 showed a verbal order entered on 12/9/23 for, Wander guard applied to left ankle for safety Change Q (every) 90 days every…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three residents sampled for abuse (Resident 10) was free from physical and verbal abuse, when confidential informant (CI1) witnessed the Director of Nursing (DON) yelling at and shaking Resident 10's wheelchair. This failure resulted in physical and verbal abuse to Resident 10 and had the potential for a decline in Resident 10's psychosocial wellbeing and isolation. Findings: During a review of the facility's policy and procedure (P&P) titled, Abuse, Resident, dated 7/15/2022, included the following statement, For all intents and purposes, the word patient(s) refers to all customers receiving health care services in our facilities, including inpatients, outpatients, residents, and clients, the P&P indicated, each patient has the right to be free from abuse (verbal, sexual, physical and mental) including corporal punishment and isolation. Patients must not be subjected to any of the above by anyone, including, but not limited to, facility…

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

Based on observation, interview and record review, the facility failed to ensure professional food safety and sanitation practices were in place when: 1. the interior of the microwave oven was not clean; 2. two expired food items were available for use; 3. one food item was not labeled with a use-by date; 4. one canned item had a dent on its seam. These failures had the potential to result in foodborne illness for a facility with a census of 79 residents who consumed food prepared in the facility. Findings: A review of The Food Code of the United States Public Health Service, and Food and Drug Administration, dated 2022, indicated the following: 4-602.13 Nonfood-Contact Surfaces. The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms (germs) which employees may inadvertently transfer to food. And, The label on packages intended for consumer sale must contain a combination of a sell-by date and use-by instructions which makes it clear that the product must be consumed within the number of days determined to…

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

The following reflects the findings of the California Department of Public Health during an abbreviated standard survey for one facility reported incident. Facility Reported Incident: 867595 The inspection was limited to the specific facility reported incident investigated and does not represent the findings of a full inspection of the facility. Representing the Department: 22705, Health Facilities Evaluator Nurse A deficiency was issued at F 557 for facility reported incident 867595. Based on observation, interview and record review, the facility failed to treat one of three sampled residents (Resident 1) with dignity and respect, when Certified Nursing Assistant (CNA) A left Resident 1 alone in the dining room, unattended with the lights turned off, after dinner. This failure resulted in Resident 1 feeling rushed and had the potential to result in a decline in psychosocial well being. Findings: The California Department of Public Health received a report from the facility on 10/27/23, which indicated CNA A left Resident 1 in the dining room, unattended with the lights turned off.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when: 1. Six dry storage bins had white and yellow-colored dried sticky substances on the lids and bottom of bins. 2. Five of the kitchen drawers had sawdust particles on the inside corners, six kitchen drawers had yellowish sticky food particles on the inside of the drawers which stored cooking utensils. 3. The kitchen microwave had yellowish food splatter on the inside including the top and both sides. 4. There was a wet dirty blue cloth stored under the cook preparation (prep) sink with visible black colored dirt and grime on the bottom of cabinet and covering the pipes. 5. The cooking utensils had dried food particles. 6. The oven had dried grease and dried food particles on the inside door, around the edges of the oven door, and on top of the oven. 7. Chipped paint on all of the white shelves in the three-door reach in refrigerators were not easily…

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 resident grievances and complaints were promptly reviewed, investigated, resolved, and documented for 1 of 26 sampled residents. (Resident 75) This had the potential for quality of care issues and neglect to continue for all residents in the facility, which could lead to negative clinical outcomes. Findings: A review of the facility's undated policy titled, Nursing Homes Residents' Rights, indicated to file a complaint or grievance, You may talk with the Resident Council in your nursing home, you may talk with a staff person you trust, or the facility administrator and talk with the long-term care Ombudsman. A review of the facility's policy dated [DATE] titled, Reporting Concerns, indicated Long Term Care will maintain records in a Concern/Grievance log, and all original documentation will be kept in the Performance Improvement Office, and studied for continuous quality improvement. During a follow up interview on [DATE] at 2:05…

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 two out of three sampled residents, (Resident 5 and Resident 182) were free from abuse and neglect when: 1. Resident 5 was verbally abused by her roommate, Resident 7. 2. A Licensed Nurse LN (A) was verbally rude, disrespectful, and did not provide care when requested for Resident 182. This failure caused Resident 7 and Resident 182 increased anxiety, loss of dignity, and humiliation. Findings: A review of the facility's policy revised and approved 3/2/23 titled, Abuse, Resident, indicated verbal abuse is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to patients/residents or their families, or within hearing distance, regardless of age, ability to comprehend, or disability. Examples include but are not limited to threats of harm, saying things to frighten a resident. Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure the facility staff recognized and reported allegations of abuse for two of two sampled residents (Residents 5 and 7) within two-hours, when resident 7 was verbally abusive and threatened resident 5 on 04/25/23 at 2:38 am, and this was not reported until 05/04/23 at 2:40 pm, 15 days later. This failure had the potential to delay the identification, and implementation of appropriate corrective actions, and placed other facility residents at risk for potential abuse. Findings: During a review of the facility's Competency Course for Education titled, Safeguarding Resident Rights in Nursing Facilities, dated 2022, the Competency Course indicated, You have the ethical and legal responsibility to protect the rights of the people your organization takes care of. A safe environment includes the right for people to be free from abuse and neglect. Every person working in a healthcare organization is responsible for protecting the people in their care 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 observation, interview and record review, the facility failed to ensure that a care plan for two of two sampled residents (Resident 5 and 7) was revised and updated to reflect an abuse allegation. This failure had the potential for resident's individual care needs to go unrecognized, and a risk for a decline in residents physical, mental, and psychological status. Findings: During a review of the facility's Policy and Procedure (P&P) titled, Care Plans-SNF dated 06/03/21, the P&P indicated, Licensed staff promptly alerts the physician to any changes that suggest a need to alter the plan of care. Changes in the resident's condition that require a change in the plan of care shall be documented in the resident's clinical record. Licensed staff will review resident care plan with weekly nursing update. Resident 5's record was reviewed. Resident 5 was admitted to the facility on [DATE], with diagnoses that included, chronic pain, anxiety, shortness of breath, and diabetes. The most recent Minimum Data Set…

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 4 of 26 sampled residents (Residents 75, 77, 181 and 182), received assistance with activities of daily living to attain or maintain their independence when: 1. Routine grooming activities were not completed for Resident 182. 2. Routine and scheduled showers and toileting were not completed for Residents 75, 77, 181 and 182. These failures had the potential to result in residents feeling depressed with poor self-esteem, and had the potential to contribute to skin breakdown, infection, and negatively impact their ability to attain or maintain their highest practicable level of well-being. Findings: A review of a facility policy titled, Quality of Life-Dignity revised August 2009, indicated residents shall be treated with dignity and respect at all times. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem or self-worth. Resident shall be groomed as they wish to be…

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 1 of 26 sampled resident's environment was free from accident hazards when the facility equipment was stored in the resident's bedroom and the resident's assistive devices were moved out of her reach. (Resident 182) This failure had the potential to increase Resident 182's risk for fall and injuries and violated her right to have a homelike bedroom environment. Findings: A review of the facility's undated policy titled, Nursing Homes Residents' Rights indicated resident right categories include the following: quality care, quality of life, and living accommodations. Resident 182 was admitted to the facility on [DATE] for diagnoses that included vascular dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), history of falling, anxiety, diabetes, chronic pain, and heart disease. During an observation on 5/3/23 at 9:30 am, Resident 182's room was full…

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 competent nursing staff when: 1. The facility staff did not understand the different types of resident abuse and the abuse policy process or to whom they should report abuse to. 2. The facility staff did not know how to implement the facility's resident grievance process. 3. The facility staff did not know that translation services were available for residents who did not speak English. 4. Facility staff did not know the process for reporting missed resident showers. This failure to ensure competent staff for facility's abuse process resulted in alleged abuse not being reported to California Department of Public Health (CDPH), the Ombudsman (resident advocacy group) and the Police, and had the potential for grievances to go unresolved and for residents who did not speak English to not have their needs met. Findings: A review of a policy revised and approved [DATE], titled Abuse, Resident, indicated verbal abuse is defined as any use…

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 identify the specific needs of and develop individualized plans of care for three of four sampled residents with dementia (the loss of cognitive functioning - thinking, remembering, and reasoning) in order to promote a high quality of life. (Residents 77, 181 and 182). This has the potential for residents with dementia to have ongoing fear, anxiety, behaviors and injuries due to the facility not recognizing and analyzing interventions tailored to their specific needs and prevent those with dementia from attaining or maintaining their highest practicable level of physical, mental, and psychosocial well-being. Findings: According to the Alzheimer's Foundation of America, November 2016, article accessed at: https://www.alzfdn.org/AboutDementia/definition.html), titled, About Dementia, dementia is a general term to describe a group of symptoms related to loss of memory, judgment, language, complex motor skills, and other intellectual function,…

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 dietary staff had appropriate competencies to carry out the functions of food and nutrition services when two quaternary sanitizer (Quat, a solution used to sanitize kitchen work surfaces) buckets had not been changed for day shift, and when tested were not at the required concentration level for effectiveness for sanitizing surfaces in the kitchen. This failure had the potential to cause foodborne illness (stomach illness acquired from ingesting contaminated food) to all residents. Findings: During a record review of the facility's policy dated 4/1/2004 titled, Law and Regulatory Affairs indicated the Oasis Multi-Quat sanitizer is registered with the Environmental Protection Agency (EPA) as a food contact surface sanitizer. The product can be used at an active ingredient concentration equal or between 150 and 400 ppm, (parts per million, a unit of measure) on food contact surfaces. During a concurrent observation and interview on 5/3/23 at 12:46 pm, the Dietary Manager (DM) checked the Quat…

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.