Sherwood Oaks Post Acute Care, LLC

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 one of six sampled residents (Resident 5) addressing weight refusals within seven days of a resident assessment indicating this issue.This failure could have resulted in the inability for staff to identify underlying reasons for weight refusals, offer alternatives, and mitigate health risks related to weight fluctuations. This oversight could have resulted in missed detection of nutritional decline for Resident 5, potentially leading to significant clinical complications. A review of Resident 5's admission Record (a facility demographic), dated 3/03/26, indicated Resident 5 was admitted to the facility on [DATE] with diagnoses including depression, severe protein-calorie malnutrition (a life-threatening deficiency of protein, carbohydrates, and fats resulting in severe muscle wasting, fat loss, or extreme fluid retention), anemia (when low red blood cell levels reduce oxygen transport to tissues, causing fatigue,…

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 monitor the side effects of a psychotropic medication (a medication that influences brain chemistry to help treat mental health conditions by affecting mood, thoughts, behaviors, and perceptions. These types of medications may be hazardous because they carry a significant risk of severe side effects) for one of six residents (Resident 4) despite recommendations from a pharmacist and a subsequent review by the facility physician.This finding had the potential to result in inability for staff to identify significant side effects of the medication which could have resulted in serious harm for Resident 4. A review of Resident 4's admission Record (a facility demographic) indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (condition where the blood supply to part of the brain is blocked or reduced), borderline personality disorder (characterized by long-term instability in emotions, behavior,…

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 the kitchen in a clean and sanitary condition for a census of 31 residents when food debris and dried liquids were present on the floor in food preparation and dishwashing areas, and a dust-covered fan was blowing onto clean utensils.This failure increased the risk of food contamination, pest attraction, and food borne illnesses for the residents of the facility.During an observation of the kitchen on 2/05/26 at 10:29 a.m., dried liquids were noted on the floor in front of the refrigerator. The floor under the refrigerators and the stove and along the baseboards was visibly soiled with food crumbs and dried food debris. The debris extended along the wall-floor seam into multiple areas. In the dish room area of the kitchen, a fan with a buildup of dark-colored dust was blowing onto clean utensils and other clean dishes on the clean side of the dishwasher deck.During a concurrent observation and interview in the kitchen on 2/05/26 at 12:30 p.m. with the Dietary Manager, the surveyor showed him the food…

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 protect one of three sampled residents (Resident 1) from abuse when Resident 2 placed Resident 1's hand on her genital area without Resident 1's consent. This failure resulted in Resident 1 experiencing emotional distress. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in July 2024 with multiple diagnoses including wedge compression fracture of lumbar vertebra (fracture of the spinal column, lower back, caused by the front of the vertebra collapsing), dementia (a progressive state of decline in mental abilities), and metabolic encephalopathy (brain does not function properly due to an imbalance in the body's metabolism). A review of Resident 1's Minimum Data Set (MDS- federally mandated assessment tool), Cognitive Patterns, dated 7/20/24, indicated Resident 1 had a Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 0 out of 15 that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide the Department a written report of the results of an abuse investigation within 5 working days of an incident that involved an abuse allegation of inappropriate touching for two of three sampled residents (Resident 1 and Resident 2). This failure had the potential to delay the Department's investigation of abuse allegations which may have led to continued abuse. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in July 2024 with multiple diagnoses including wedge compression fracture of lumbar vertebra (fracture of the spinal column, lower back, caused by the front of the vertebra collapsing), dementia (a progressive state of decline in mental abilities), and metabolic encephalopathy (brain does not function properly due to an imbalance in the body's metabolism). A review of Resident 1's Minimum Data Set (MDS- federally mandated assessment tool), Cognitive Patterns, dated 7/20/24, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident was free from abuse when Resident 1 hit with her fist Resident 2's thigh while they were seated close to each other. This failure caused pain and potential mental anguish to Resident 2. Findings: A review of Resident 1's medical records indicated the following: - The Quarterly Minimum Data Set (MDS - federally mandated clinical assessment) dated 9/23/24 indicated Resident 1 had severe memory issues. - The MDS further indicated Resident 1 had delusions (misconceptions or beliefs that are firmly held, contrary to reality) and exhibited verbal behavior symptoms directed towards others such as threatening, screaming, and cursing at others; - Resident 1's order summary report for 12/2024 indicated she was receiving Quetiapine Fumarate (an antipsychotic - medications used to treat several kinds of mental health conditions to regulate your mood, behaviors and thoughts) 50 milligram (mg, unit of measure) tablet in the afternoon and 25 mg in…

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

Based on interview and record review, the facility failed to report an alleged resident abuse immediately when Resident 1 allegedly hit Resident 2 who was sitting near and opposite her. This failure reduced the faciltiy's potential to ensure resident safety. Findings: A review of facility Transmission Verification report sent 11/11/24 at 4:52 p.m. and received by the Department on 11/12/24 at 8:00 a.m., indicated an allegation of suspected dependent adult/elder abuse had been made related to a resident-to-resident altercation between Resident 1 and Resident 2. A review of the Report of Suspected Dependent Adult/Elder Abuse (documenting a report of abuse or neglect of an elder or dependent adult) between Resident 1 and Resident 2, indicated the incident happened on 11/10/24, at 4:18 p.m. During a review of record and concurrent interview on 12/23/24 at 11:45 a.m., the facility's abuse prevention policy did not indicate a timeframe for reporting suspected abuse incidents. The DON stated they follow the flowchart of Mandated Reporter (attached in facility documents) posted on his…

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 upon interview and record review the facility failed to have a dedicated full time Director of Nursing. This failure had the potential to put residents at risk for a multi-faceted role of Director of nursing, charge nurse and MDS (Minimum Data Set, a clinical assessment of the resident's functional capabilities and helps staff identify health problems) coordinator whereby the residents were not given the appropriate oversight by a dedicated Director of Nursing. Findings: During an interview on 2/15/24 at 11:05 a.m., Director of Nursing (DON) indicated he was currently the DON, MDS coordinator and floor nurse who administers medications among other duties. During an interview on 2/15/24 at 12:10 p.m., with Director of Staff Development (DSD), DSD indicated DON worked the medication cart passing medication or administering medications to residents every day, (Monday to Friday) DSD indicated the days she would come to work, she would pass medications for DON so he may focus on other duties. DSD indicated if there were issues with the licensed and unlicensed staff then the DON…

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

Based on interviews and record reviews, the facility failed to ensure they were electronically submitting Payroll Based Journal (PBJ, a system that facilitate the submission of staffing information) data as required every quarter when the Certification and Survey Provider Enhanced Reporting system (CASPER, an assortment of real-time data that allows skilled nursing facilities (SNFs) the opportunity to pinpoint areas where changes in care and operations are necessary to improve performance) report indicated there was no information for the first quarter (Q1 1/2024 up to 3/2024). Findings: During an interview on 5/22/24 at 10:00 a.m., the Administrator Assistant (AA) stated she did not know how to submit report for PBJ. The AA stated another staff from their sister facility submits the facility's PBJ information to Centers for Medicare and Medicaid Services (CMS, works in partnership with the entire health care community to improve quality, equity and outcomes in the health care system). During an interview on 5/22/24 at 3:04 p.m., the Administrator stated PBJ staffing information…

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 facility document review, the facility's Quality Assurance and Performance Improvement Program (QAPI, a data driven and proactive approach to quality improvement. It combines two approaches - Quality Assurance (QA) and Performance Improvement (PI). QA is a process used to ensure services are meeting quality standards and assuring care reaches a certain level.) failed to identify quality deficiencies as evidenced by: 1) One sampled resident (Resident 12) self-administered and stored his medications in his room. 2) lack of management oversight that resulted in missing narcotics. There was no investigation or report made to the appropriate agencies until one of the surveyors discovered this deficient practice. 3) lack of protocol and facility's effort to monitor residents and obtain referral and treatment for residents (Resident 1) that were hard of hearing. 4. lack of facility's monitoring and tracking residents that were in need of oral care. 5. lack of monitoring to ensure DHPPD meet the minimum hours required for direct care staffing. 6. lack of Restorative…

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 identify three instances of abuse, when: 1) One unlicensed staff member withheld food for one resident (unidentified resident) due to the resident's behavior; 2) Staff neglected to change briefs soiled with urine and feces, resulting in skin breakdown (no specific resident was identified) and staff verbally abused a resident (Resident 19), who was one out of one sampled resident. These failures to identify abusive behavior from a staff member toward residents created an environment where residents' rights were violated, and the residents were fearful to report any abusive behaviors from the staff for fear of retaliation. Findings: During a telephone interview on 2/8/24 at 8:35 a.m., a Complainant indicated there were bad things going on between a staff person and the residents, but specifically something happened around 1/25/24, and it was bad. The Complainant indicated the resident involved wanted anonymity and no names were identified. The Complainant indicated, since the Administrator started working at the building in…

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

Based on interview and record the facility failed to identify and report three instances of abuse when the Administrator had documented disciplinary actions (1/21/24, 1/22/24 and 2/6/24) for one unlicensed staff (Unlicensed Staff C) and did not notify the Department. These failures to report abusive behavior from unlicensed staff towards residents created an environment where residents' rights were violated, and the residents were fearful to report any negative behaviors from staff due to retaliation. Findings: During a telephone interview on 2/8/24 at 8:35 a.m., with a Complainant, the Complainant indicated there were bad things going on between a staff person and the residents, but specifically something happened around 1/25/24, and it was bad. The Complainant indicated the resident involved wanted anonymity and no names were identified. The Complainant indicated, since Administrator started working at the building in 2022, the residents and staff would not discuss concerns or issues. The Complainant indicated the residents were fearful the building would close if any complaints…

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 send a copy of Notice of Discharge or Transfer to the representative of the Office of the State Long Term Care (LTC) Ombudsman (a public advocate (official) is an official who is charged with representing the interests of the public by investigating and addressing complaints of maladministration or a violation of rights) for four Resident's: Residents 85, was discharged to home, and Residents 86, 87 and 88 were transferred to acute facilities. These failures had the potential for Residents (Resident 85, 86, 87 and 88) were not being provided an advocate who could inform them of their rights and options before being discharge to home or transferred to an acute care facility out of 36 sampled residents. Findings: During a concurrent interview and record review on [DATE] at 2:21 p.m., with Social Services Assistant (SSA), SSA reviewed, a resident who had been discharged and when reviewing the electronic medical record, the progress note did not indicate…

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: 1. basic care plans (BCP, a plan that promotes continuity of care and communication among nursing home staff to increase resident safety) were completed timely for one out of four sampled residents (Resident 6). 2. the Interdisciplinary Team (IDT, a group of dedicated healthcare professionals who work together to provide you with the care you need) reviewed the physician's order and implement the BCP to meet the residents immediate care needs, initial goals, physician's orders, dietary orders, therapy services, social services and Preadmission Screening and Resident Review (PASRR, Preadmission Screening and Resident Review (PASRR, a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) recommendations if applicable for four out of four sampled residents (Residents 6, 12, 27 and 31). 3. residents or their representative were provided a summary of the BCP for four out of 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 observations, interviews and record reviews, the facility failed to ensure oral care was provided regularly and per plan of care for one out of six sampled residents (Resident 31). This failure led to Resident 31 having a thick whitish, yellowish tinged material on her tongue and could put Resident 31 at risk for dental caries, bad breath and infections. Findings: A review of Resident 31's face sheet (demographics) indicated he was initially admitted to the facility on [DATE]. Her diagnoses included Hyperlipidemia (HLP, high cholesterol is an excess of lipids or fats in your blood), Essential Hypertension (HTN, high blood pressure) and Failure to Thrive (FTT, a decline in older adults that manifests as a downward spiral of health and ability). Her Minimum Data Sheet Assessment (MDS, a federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes) dated 3/25/24, Brief Interview for Mental Status (BIMS, a mandatory tool used to screen and identify 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 interviews and record review, the facility failed to ensure a significant weight change was reported to the physician and the Registered Dietician (RD) for one out of six sampled residents (Resident 6), when: 1.Resident 6 lost 12.8 pounds (#, a measure of weight) or 7.6 percent (%, a relative value indicating hundredth parts of any quantity) between 4/2023 and 5/2023. 2.Resident 6 gained 17.8# or 11.5 % between 5/2023 and 8/2023. These significant weight changes, if not reported to the physician and RD, could put Resident 6 at risk for increased mortality and subsequent occurrence of adverse health outcomes. A review of Resident 6's face sheet (demographics) indicated he was initially admitted to the facility on [DATE]. His diagnoses included Parkinsonism (a term used to describe the collection of signs and movement symptoms associated with several conditions), Feeding Difficulties (behavioral conditions characterized by severe and persistent disturbance in eating behaviors) and Muscle Weakness. His…

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 they were adequately staffed when: A.six out of six sampled residents (Residents 12, 13, 20, 24, 27 and 31) complained the facility was short staffed. B. for the month of 4/2024, the total direct care service hours patient per day (DHPPD, staffing requirement ) was not met for 24 out of 30 days on these dates: 4/1/24, 4/4/24, 4/6/24, 4/7/24, 4/9/24, 4/10/24, 4/11/24, 4/12/24, 4/13/24, 4/14/24, 4/16/24, 4/17/24, 4/118/24, 4/19/24, 4/20/24, 4/21/24, 4/23/24, 4/24/24, 4/25/24, 4/26/24, 4/27/24, 4/28/24, 4/29/24, 4/30/24 and the Certified Nursing Assistant (CNA) PPD was not met for 28 out of 30 days on these dates: 4/1/24, 4/2/24, 4/3/24, 4/4/24, 4/4/24, 4/5/24, 4/6/24, 4/7/24, 4/8/24, 4/10/24, 4/11/24, 4/12/24, 4/14/24, 4/15/24, 4/16/24, 4/17/24, 4/18/24, 4/19/24, 4/20/24, 4/21/24, 4/22/24, 4/23/24, 4/24/24, 4/25/24, 4/26/24, 4/27/24, 4/28/24, 4/29/24, 4/30/24. C. for the month of 5/2024, the total DHPPD was not met on 6 out of 20 days on these…

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

Based on interviews and record reviews, the facility failed to ensure staff have the specific competencies and skill sets necessary to care for residents' needs when: 1.staff did not know what a Baseline Care Plan (BCP, should be developed within 24 hours of admission and contain the minimum health care information necessary to care for the residents) was, and its completion time frame. 2. staff did not know what a Trauma Informed Care (TIC, an approach care that acknowledges the complete picture of a resident's life situation, past and present, to provide effective health care services with a healing orientation and prevent retraumatization) was. These failures could put residents at risk for unsafe, inadequate, and ineffective care. During an interview on 5/22/24 at 8:25 a.m., the Director of Staff Development (DSD) stated she was not aware of what BCP was and stated she did not know the timeframe for completing a BCP. However, the DSD stated if a care plan (CP, a form that summarizes a person's health conditions and current treatments for their care) was not completed timely it…

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 ensure: 1. staffing information was posted in a prominent place readily accessible to residents and visitors, when the nursing staffing information was kept in a binder behind the counter at the nursing station 2. staffing information was accurate and current. 3. staffing information was complete and was not missing information when the nursing home patient per day (NHPPD, the actual nursing hours performed by direct caregivers per patient day) was left blank. These failures resulted in the nurse staffing information being inaccessible to residents and visitors at any given time and the facility not meeting the NHPPD staffing requirement (cross reference F725). Findings: During an observation on 5/20/24 at 4:00 p.m., there was no visible staffing information posted in the building or at the nursing station. During a concurrent observation, interview, and staffing information, dated 5/21/24, record review on 5/21/24 at 11:15 a.m., Licensed Staff D verified there was no visible staffing information posted in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to ensure for one out of eight sampled residents (Resident 12): 1. all his medications were secured in a locked storage area with limited access to authorized personnel consistent with state or federal requirements and professional standards of practice. This failure resulted in unsecured and unsafe storage of all the medications of Resident 12 which was a huge safety risk not only to Resident 12 but also to the other residents at the facility. 2. the facility followed their procedures for ensuring his safety when he was self-administering his medications. This failure put Resident 12 at risk for accessing and ingesting medications that could cause clinically significant adverse consequences, worsening of his symptoms which could also result to serious harm or death. Findings: A review of Resident 12's face sheet (demographics) indicated he was initially admitted to the facility on [DATE]. His diagnoses included Hyperlipidemia (HLP, 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.

Based on observations and interviews, the facility failed to provide residents with food that was palatable (Palatability may influence food choice as it is proportional to the pleasure someone experiences when eating a particular food. It depends on the sensory properties of the food such as taste, smell, texture, sound, and sight). This failure had the potential to result in nutritional problems if the residents declined to eat the food served by the facility. Findings: During an interview on 5/20/24, at 2:54 p.m., with Resident 12, he stated the food was bad and canned vegetable food that was being served were mushy. He stated the food served had no taste, sometimes served cold. He stated sometimes he did not eat the food provided by the facility. During an interview on 5/20/24, at 3:44 p.m., with Resident 27, he stated the food was not great but did not elaborate what his concerns were with the food served by the facility. During an interview on 5/20/24, time not specified, with Resident 7, she stated she was not getting fresh food. She stated food served was mostly frozen, 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 observations, interviews, and record reviews, the facility failed to ensure that: 1. clean linens were transported from the laundry room to the clean storage areas of the facility by methods that promoted cleanliness and protection from dust and soil, when the linen cart used for the transport was not covered. 2. staff perform hand hygiene (HH, a term used to cover both hand washing using soap and water, and cleaning hands with waterless or alcohol-based hand sanitizers (an alcohol-containing preparation (liquid, gel or foam) designed for application to the hands to inactivate microorganisms and/or temporarily suppress their growth) was being done by staff prior to assisting residents with their meal and staff were offering to the residents HH before and after meals for three out of three sampled residents (Residents 6, 24, and 27) 3. urinals (a vessel for receiving urine) with collection of urine were not hung on resident's walker for one out of two sampled residents (Resident 12), and was not left 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 interview and record review, the facility failed to coordinate the Level II Preadmission Screening (PASARR) after a positive result for Level I PASARR) for one (1) of eight (8) residents, Resident 17. This failure resulted in a delay of MD's evaluation for mental illness and a delay of care and services needed for Resident 17. Findings: Level II PASARR is a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in a nursing home for long term care. A record review of Resident 17 titled admission record indicated she was initially admitted to the facility on [DATE] with mental illness (MI). A record review of Resident 17's evaluation titled Level I PASARR dated 08/10/21 was positive indicated a Level II PASARR mental health evaluation from Department of Health Services was required. A review of the regulatory health and safety code § 483.20(e)(1) Incorporating the recommendations from the PASARR level II determination 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 ensure for one out of six sampled residents (Resident 12): 1.was using his continuous positive airway pressure (CPAP, a breathing therapy device that delivers air to a mask worn over the nose) every night at bedtime and staff was assisting him on putting on his CPAP mask. 2.staff obtained a physician order for the setting of his CPAP machine. 3.staff put on a no smoking signage in his room since he was using a CPAP. These failures could lead to daytime Fatigue (lack of energy), high Blood Pressure, low oxygen levels, increased Blood Sugar, elevated heart rate, headaches, and mood changes. Findings: A review of Resident 12's face sheet (demographics) indicated he was initially admitted to the facility on [DATE]. His diagnoses included Hyperlipidemia (HLP, high cholesterol is an excess of lipids or fats in your blood), Essential Hypertension (HTN, high blood pressure) and Muscle Weakness. His Minimum Data Sheet Assessment (MDS, a federally…

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 ensure for one out of six sampled residents (Resident 1) 1.in gaining access to hearing services by obtaining an audiologist (a specialist in the treatment of hearing disorders) referral. 2. making an appointment to see an audiologist. 3 .Resident 1's hearing aids (HA, a small electronic devices that amplify sound, help improve hearing and speech comprehension in people with hearing loss) were checked for functionality. These failures led to Resident 1's having difficulty in hearing spoken words. These failures put Resident 1 at risk for miscommunication, frustration and difficulty understanding spoken words. Findings: A review of Resident 1's face sheet (demographics) indicated he was initially admitted to the facility on [DATE]. Her diagnoses included Hyperlipidemia (HLP, high cholesterol is an excess of lipids or fats in your blood), Type 2 Diabetes Mellitus (DM, disease caused by a problem in the way the body regulates and uses sugar…

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

Based on interviews and record reviews, the facility failed to ensure that one out of four sampled residents, Resident 23, received Range of Motion (ROM- means the extent or limit to which a part of the body can be moved around a joint or a fixed point; the totality of movement a joint is capable of doing. Range of motion of a joint is gauged during passive ROM (assisted) PROM or active ROM (independent) AROM) exercises as ordered by her physician and according to her comprehensive care plan. This failure had the potential to result in the development of new contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) or worsening of contractures to her left and right ankles that could affect her health and well-being. Findings: A review of Resident 23's admission Record, dated 5/23/24, indicated that her principal diagnosis was Multiple Sclerosis (a chronic degenerative, often episodic disease of the central nervous system marked by patchy destruction of the myelin that surrounds and insulates nerve…

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 employ a Certified Dietary Manager with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, when there was no designated full time Director of Food and Nutrition Services onsite, as required, when the facility's Registered Dietitian was not employed on a full-time basis. This failure had the potential to result in food borne illnesses when no oversight was provided to the dietary staff during food preparation and could affect the health and safety of all residents of the facility. Findings: During a concurrent observation and interview on 9/14/23, at 2:15 p.m., with Dietary Staff A, the dietary manager was not in the facility. Dietary Staff A stated Dietary Staff B was the dietary manager, and if there were issues in the kitchen, he would contact her by phone. During an interview on 9/14/23, at 2:40 p.m., with CNA C (Certified Nursing Assistant C), she stated she had not seen this dietary manager (Dietary Staff B) in the building. CNA C stated, This is…

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

Based on observation, interview, and record review, the facility failed to ensure the Registered Dietician (RD) provided comprehensive oversight of the dietary services. Failure to ensure comprehensive oversight by the RD might have resulted in: 1. menus were not followed. Refer to F 803; 2. facility did not follow physician prescribed therapeutic diets. Refer to F 808; and 3. the facility did not store and prepare food in accordance with professional standard. Refer to F 812. This failure also had the potential for systematic failures of nutrition service and impaired quality of life for all 35 residents in the facility and had the potential to cause widespread food-borne illness in a vulnerable population with complex medical conditions. Findings: During multiple observations, interviews, and record reviews, from 5/16/22 - 5/20/22, at various times through out the day, nutritional services were provided in a manor that did not meet the 2017 Food Code standards. During an interview with the RD, on 5/20/22, at 10:16 a.m., the RD stated she had been contracted to provide RD services…

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 store and prepare food in accordance with professional standards for food service safety when: 1. eggs were purchased for resident consumption that were not pasteurized, 2. food was stored past the facility's use by date, 3. food was stored in open packaging, 4. fruits and vegetables stored for use had mold spots, had turned brown, and had gotten soft and squishy, 5. food containers were removed from their external packaging and stored without documentation to show the products expiration date, 6. prepared food was stored and ready for use past the facility's policy, 7. food preparation areas were not cleaned or sanitized between uses, 8. staff did not perform hand hygiene after removing their gloves, 9. the solution used to sanitize kitchen surfaces was not at an acceptable concentration per the manufacturer's guidelines 79 times out of 79 opportunities, 10. the internal components of the ice machine were not drained, cleaned, and sanitized as needed or according to the manufacturer's specifications, 11. the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents received the necessary care and services to ensure resident's abilities to perform Activities of Daily Living did not decline when Restorative Nursing Assistant (RNA) services (RNAs perform range of motion exercises and strengthening exercises) were not provided as ordered for four Residents (Resident 4, Resident 84, Resident 28 and Resident 23). This failure had the potential to result in decline of resident's Activities of Daily Living (ADL)(The ability to be able to eat, wash, shower, brush teeth, walk, transfer to a toilet or wheelchair independently or with minimal assistance.), and contractures (A condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). Findings: 1. During an observation and interview on 5/17/22, at 8:34 a.m., Resident 4 was observed seated in his wheelchair at his bedside. He stated he had not had and Physical Therapy (PT) or RNA…

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 enough staff to meet the needs of residents, when Restorative Nursing Assistant (RNA) services were discontinued and used RNA staff as a Certified Nursing Assistant (CNA). This failure had the potential to result in resident falls, skin breakdown, and residents decline of resident's Activities of Daily Living (ADL)(The ability to be able to eat, wash, shower, brush teeth, walk, transfer to a toilet or wheelchair independently or with minimal assistance.), and contractures (A condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). Findings: (Reference F676) 1. During an observation on 5/16/22, at 11:05 a.m., the white board in Nurse Station 1 indicated Licensed Nurse P, Unlicensed Staff Q, Unlicensed Staff R, and Unlicensed Staff S on duty. During an interview on 5/16/22, at 12:36 p.m., Resident 4 stated staffing was really short. He stated the short staffing had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure menus were followed when; 1. 3 out of 3 recipes were not followed for the lunch meal served on 5/19/22, 2. All Residents were given 2 slices from a 5 inch personal pizza rather than 2 slices from a twelve inch pizza for the dinner meal served on 5/16/22, 3. The wheat roll was omitted from the lunch meal served on 5/16/22, a substitution was not offered, 4. 1 resident on a pureed diet (Resident 8) received the wrong dessert item for 1 lunch meal served on 5/19/22. These failures resulted in altered nutritional content of the menu and put vulnerable residents at risk for imbalanced nutrition, weight loss and worsening of medical conditions. Findings: 1a. During a review of the facility document titled, Good For Your Health Menus, dated 5/16/22-5/23/22, the menu indicated what was expected for lunch on 5/19/22. The menu indicated Szechuan pork, fried rice, stir fry vegetables, confetti coleslaw, and tapioca pudding would be served.…

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

Based on observation, interview, and record review, the facility failed to follow the physician prescribed therapeutic diets when: 1. Mechanical Soft (MS) texture was not followed during the 5/19/22 lunch meal, which increased the risk for choking for residents with chewing or swallowing difficulty; 2. High protein diets were not followed, which had the potential for worsening nutritional status of residents that needed protein dense meals. Failure to follow physician ordered diets had the potential to compromise the medical status for all 23 residents with a therapeutic diet. Findings: 1. During an observation, on 5/19/22, at 12:10 p.m., in the kitchen, Dietary G removed 8-10 scoopfuls of pork and put them into a food processor. Dietary G pulsed the food processor 4 short pulses and 2 long pulses. During a concurrent interview and record review, on 5/19/22, at 12:25 p.m., with the DM and Dietary G, Dietary G stated the pork in the food processor was used for residents on a mechanical soft diet. Dietary G stated the small, chopped up pork pieces were appropriate for residents on a…

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

Based on interview and record review, the facility failed to ensure an active and engaged Quality Assurance and Performance Improvement committee. This failure had the potential to not proactively identify resident care issues and develop a sustainable plan to address the concerns. Findings: During an interview and record review, with the Administrator, on 5/20/22 at 12:31 p.m., she stated she had started as the Administrator in April 2022, and had met once with the Quality Assurance Performance Assurance Committee. She could not provide a Quality Assurance Performance Improvement Plan, approved by the QAPI Committee or Governing board for 2022. She stated she had prioritized to work on Dietary Remodeling Issues and Staffing. The Administrator stated she had not fully developed the QAPI process at this time. A review of the QAPI minutes indicated the committee met in April, but had not fully developed any Performance Improvement Projects to address Falls Prevention, Staffing shortages, Suspension of the Restorative Nursing Assistant program, Pharmacy Recommendations, or Dietary…

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 a safe discharge plan for one of one sampled residents (Resident 26) when 1) the facility did not discuss Resident 26's facility-initiated discharge plan with the resident's daughter or obtained the daughter's agreement to care for Resident 26, and 2) the facility-initiated discharge plan to discharge Resident 26 to a location that was not determined by the choice or the best interests of Resident 26. This failure resulted in Resident 26 feeling very upset and had to go through an appeal process. Findings: The intake information sheet dated 4/28/22 indicated that the Department (the California Department of Public Health) received an anonymous complaint on 4/28/22 regarding a involuntarily discharge of a resident. The complaint information included that the resident had gone through an appeal process with the Office of Administrative Hearing and Appeals. The resident was granted to be remained in the facility due to the facility did not provide…

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.