Fortuna Rehabilitation And Wellness Center, LP

Based on interviews and record review, the facility failed to ensure allegations of abuse were reported to the California Department of Public Health (CDPH, the Department) within two hours and investigation summaries were submitted within 5 days of becoming aware of allegations of abuse for 11 residents (Resident 00, Resident 83, Resident 101, Resident 90, Resident 105, Resident 102, Resident 2, Resident 74, Resident 14, Resident 68, and Resident 65) of 28 sampled residents when:1. Resident 00 entered Resident 83 and Resident 101's room and started breaking their belongings, cursing profanities, and yelling at them;2. Resident 90 threw water at Resident 105;3. Resident 102 was allegedly yelled at by CNA 8 and was told she needed to stop peeing on herself;4. Resident 2 slapped Resident 74 on the hand;5. Resident 14 allegedly grabbed Resident 90 because he had called him 'dude';6. Resident 68 was instructed to urinate in her brief by CNA 4 when Resident 68 asked for assistance to use the restroom; and,7. Resident 65 was allegedly hurt by CNA 8 while providing personal care.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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide the resident and/or their Responsible Party (RP, an individual or entity who has the primary duty to make healthcare decisions) with a summary of the resident's baseline plan of care and list of medications for three residents (Resident 41, Resident 46, and Resident 96) of 28 sampled residents.This failure decreased the facility's potential to provide communication with the residents and/or their RP on how the facility planned to manage needed services and treatments while at the facility.Findings:A review of Resident 41's admission record indicated admission to the facility on 8/30/25, with diagnosis including Pneumonia (lung infection), Alcohol Dependence, Alcohol Use with Withdrawal, Type Two Diabetes (elevated sugar in the blood), and he was his own RP.A review of Resident 41's baseline care plan signed and dated by the Minimum Data Set Coordinator (MDSC) as completed on 9/3/25, indicated Resident 41was provided with a current medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop comprehensive care plans for four residents (Resident 62, Resident 41, Resident 46, and Resident 96) of 28 sampled residents when:1. Care plans were not developed for care areas identified by Resident 62's Minimum Data Set (MDS- a federally mandated resident assessment tool); and,2. Discharge care plans were not developed for newly admitted residents (Resident 41, Resident 46, and Resident 96), after their initial multidisciplinary care conference.These failures decreased the facility's potential to meet residents' nursing needs and ensure safe discharges.Findings:1. A review of Resident 62's admission record indicated a readmission to the facility on 7/8/25, with diagnosis including Discitis (an infection and swelling of the spongy, cushion-like disc between the bones in your spine (backbone)), Osteomyelitis (a bone infection caused by bacteria or other microorganisms), back pain, Congested Heart Failure (progressive condition where the heart…

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 medications in medication carts (med carts) were stored in a clean, safe and orderly manner, when:1. Crushed and loose medications were stored in Med Cart 4; and,2. One med cart (Med Cart 1) was left unlocked when unattended.These failures had the potential for residents, visitors or unauthorized personnel to access medications, and unwanted exposure or cross contamination of medications when they were in an unsanitary manner. Findings:1. During a concurrent observation and interview on 9/16/25 at 3:20 p.m. with Licensed Nurse 4 (LN 4), at Med C art 4, the following was observed:a. One 30 milliliter (ml, a unit of measurement) plastic medication cup which contained a brown chunky substance was stored in the top drawer; and, b. One loose capsule and 8.5 loose tablets were found in various drawers.LN 4 stated the plastic medication cup contained crushed medications mixed with chocolate pudding and had been prepared for resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to honor the food preferences for three residents (Residents 14, 46, and 97) of 28 sampled residents. These failures resulted in Residents 14, 46, and 97 feeling ignored and frustrated as they were served food they disliked, which may lead to poor nutritional intake and unplanned weight loss.Findings:A review of Resident 46's admission record indicated Resident 46 was admitted to the facility on [DATE], with diagnosis including Malignant Neoplasm (cancer) of Rectum (the final section of your large intestine).A review of Resident 46's Nutritional Risk Assessment effective date 8/21/25, indicated Resident 46 did not like raw fruits and vegetables. A review of Resident 46's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 8/22/25, indicated Resident 46 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)…

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 review the facility failed to ensure sanitary conditions were maintained and failed to follow Standard Precautions (proper cleaning and disinfection of equipment) for a census of 94 residents, when:1. Resident 1's bedside commode (BSC, a portable toilet) was not kept in a clean and sanitary manner;2. The metal ice scoop on the hydration cart was not stored in a sanitary manner; and,3. Staff did not disinfect the vital sign machine and equipment between use for five residents (Residents 83, Resident 77, Resident 82, Resident 28, and Resident 88).These failures decreased the facility's potential to prevent the spread of infection and pathogens (microorganisms or other biological agents that can cause disease) between residents.Findings: 1. A review of Resident 1's admission record indicated admission to the facility in December 2023 with diagnoses which included muscle weakness and unstable gait and mobility. During an observation on 9/15/25 at 9:35 a.m. in Resident 1's room, a BSC was observed positioned next to Resident 1's bed. The BSC…

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 an effective pest control program for a census of 94 residents when flies were observed flying throughout the facility.This resulted in residents being bothered by flies in their room, flies in the Great Dining Room while residents were trying to eat their meals, and flies in the kitchen which could lead to contamination of food being prepared. Findings:During a dining room observation on 9/15/25 at 12:45 p.m., the door leading from the dining room to the outside resident patio was wide open during lunchtime without any screens to prevent pests from entering. Flies were noted in the dining room. A picture of a fly on a resident's arm and a picture of a fly on the resident coffee dispenser was taken during the lunch meal.During an observation on 9/15/25 at 5:31 p.m., three flies were continuously buzzing around while Resident 14 swatted at them.During a concurrent observation and interview on 9/16/25 at 2:40 p.m., both the Regional Registered Dietician (RRD) and the Certified Dietary Manager (CDM)…

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 residents (Resident 74, Resident 83, Resident 101, Resident 105, and Resident 68) of 28 sampled residents were free from abuse when:1. Resident 2 slapped Resident 74 on the hand;2. Resident 00 entered Resident 83 and Resident 101's room and started breaking their belongings, cursing profanities, and yelling at them;3. Resident 90 threw water at Resident 105; and,4. Certified Nursing Assistant 4 (CNA 4) instructed Resident 68 to urinate in her brief when Resident 68 asked for assistance to use the restroom.These failures resulted in residents being hit, feeling fear, and being neglected.Findings:1. A review of Resident 2's admission record indicated admission to the facility on 2/20/24 with diagnoses which included metabolic encephalopathy (a change in the brain's function due to an underlying condition), dementia (a progressive state of decline in mental abilities), cerebral infarction (also known as a stroke, when blood flow to the brain…

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 one of eight sampled residents, (Resident 2) was free of unnecessary psychotropic medications (drugs that affect the mind and brain, altering mood, perception, and behavior) when Resident 2 received: Haloperidol (an antipsychotic medication) used to treat to treat schizophrenia and Tourette's Syndrome (disorder characterized by involuntary, repetitive movements or sounds called tics); and, Quetiapine fumarate (an antipsychotic medication used to treat schizophrenia (a mental illness that is characterized by disturbances in thought) and bipolar disorders (mental illnesses that are characterized by mood swings that range from the lows of depression to elevated periods of emotional highs)).with inadequate indications (a specific disease, condition, or symptom for which the drug is approved to be used to treat, prevent, or diagnose) for prescribing.This failure resulted in Resident 42 suffering from sedation (sleepiness caused by…

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

Based on interview and record review, the facility failed to implement its policy and procedure for abuse for one resident (Resident 65) of 28 sampled residents when licensed nurses and the social service worker did not assess Resident 65 for emotional distress after Resident 65 reported an allegation of abuse.This failure decreased the facility's potential to ensure the safety and welfare of Resident 65 after an allegation of abuse was reported.Findings:A review of an admission record indicated Resident 65 was admitted to the facility in September 2023 with diagnoses which included heart failure, chronic respiratory failure, and muscle wasting and atrophy (muscle shrinking).In an interview on 9/15/25 at 9:54 a.m., Resident 65 stated a Certified Nursing Assistant 2 (CNA 2) was rough while providing her care the night before. Resident 65 stated CNA 2 made her feel afraid and added, If I was floating in my urine, I would not call him in [to help me]. Resident 65 further stated she reported the incident to CNA 3 this morning.In an interview on 9/15/25 at 4:37 p.m., Resident 65 reported…

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 licensed nurses provided two residents (Resident 2 and Resident 74) of 28 sampled residents care that met professional standards of practice when neurological assessments were not completed per the facility's fall protocol after Resident 2 and Resident 74 had unwitnessed falls.These failures decreased the facility's potential to provide the expected nursing care indicated in resident care plans and accepted standards of practice.Findings:A review of Resident 2's admission record indicated admission to the facility on 2/20/24 with diagnoses which included metabolic encephalopathy (a change in the brain's function due to an underlying condition), dementia (a progressive state of decline in mental abilities), cerebral infarction (also known as a stroke, when blood flow to the brain is interrupted, which causes brain cells to die), and cognitive communication deficit (difficulty in communication caused by impaired brain function).A review of…

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

Based on interview and record review, the facility failed to recognize, report, and address the nutritive needs of one resident (Resident 62) of 28 sampled residents when Resident 62 lost 9.8 pounds between 8/6/25 and 9/5/25.This failure led to Resident 62 experiencing an unplanned weight loss without timely notification to the Director of Nursing, Physician, or Registered Dietitian per the facility's weight evaluation policy, thereby delaying necessary intervention. Findings:A review of Resident 62's admission record indicated admission to the facility on 6/6/25 with diagnosis including Discitis (an infection and swelling of the spongy, cushion-like disc between the bones in your spine [backbone]), Osteomyelitis (a bone infection caused by bacteria or other microorganisms), Congested Heart Failure (progressive condition where the heart muscle weakens and can no longer pump blood effectively), Type 2 Diabetes (high blood sugar), Hypothyroidism (a condition in which the thyroid gland does not produce enough hormones to regulate metabolism (how your body turns food and drink into…

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 routine and emergency drugs were available for a census of 94 residents, when:1. Resident 73's routine buprenorphine - naloxone (a controlled substance used for chronic pain management) was unavailable for administration; and,2. The facility's oral and insulin emergency medication kits (e-kit) were not replaced within a timely manner.These failures decreased the facility's potential to meet residents' routine scheduled and emergency therapeutic needs.Findings:1. A review of Resident 73's admission Record indicated admission to the facility in June 2024 with diagnoses which included chronic pain syndrome and anxiety disorder (excessive worry, fear and nervousness that can interfere with daily life).A review of Resident 73's Order Summary Report (OSR, physician orders) dated 9/18/25, indicated an order to give one tablet of buprenorphine - naloxone 8-2 milligrams (mg, a unit of measurement) sublingually (under the tongue) four times…

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

Based on observation, interview, and record review, the facility failed to provide nourishment that was palatable, textured, and attractive for one resident (Resident 58) of 25 sampled residents when a liquified pureed diet was provided contrary to the Responsible Party (RP, an individual or entity who has the primary duty to make healthcare decisions for a resident) and family preference and concern.This failure resulted in weight loss and a lack of dignity for Resident 58.Findings:A review of Resident 58's admission record indicated admission to the facility on 8/27/16 with diagnoses which included Alzheimer's disease (a progressive, irreversible brain disorder that causes memory loss, confusion, and other cognitive decline), type 2 diabetes (a chronic condition where the body does not use insulin effectively or does not produce enough insulin to regulate blood sugar levels), protein calorie malnutrition (a condition that occurs when a person does not consume enough protein and calories to meet their body's needs), and dysphagia, oropharyngeal phase (difficulty or inability 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.

Based on observation, interviews and record review, the facility failed to ensure frozen vegetables stored in the freezer were sealed for 90 residents who received food from the facility's kitchen.This failure could cause frozen vegetables to develop freezer burn, which could negatively affect the quality of the vegetables by causing the vegetables to be dry, tough, and flavorless and had the potential to result in cross contamination leading to foodborne illnesses.Findings:During the initial tour of the kitchen on 9/15/25 at 8:50 a.m., three boxes of frozen vegetables carrots, green beans and corn were opened and not sealed in the walk-in freezer. The frozen vegetables that were opened were stored in their original blue plastic bags, which were open to air and placed back in their original cardboard boxes. The Certified Dietary Manager stated if frozen items are not sealed tightly, they could get freezer burn.During an interview on 9/16/25 at 12:30 p.m. the Regional Registered Dietician stated if a frozen vegetable was not sealed tightly, she would be concerned that something could…

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 review, the facility failed to ensure resident safety for one resident (Resident 6) out of 25 sampled residents when the call light was out of reach.This failure decreased the facility's potential to ensure Resident 6's ability to notify staff if there was an emergency.Findings:A review of Resident 6's admission record indicated he was admitted to the facility in April 2022 with diagnoses which included cerebral infarction (when blood flow to the brain is interrupted causing tissue damage) and Post Traumatic Stress Disorder (PTSD, a mental health condition that develops after experiencing or witnessing a traumatic event).A review of Resident 6's Care Plan (CP, a comprehensive, individualized plan of care) indicated the following concerns and interventions:1. Risk for falls: ensure the call light was within reach and needs prompt response to all requests for assistance, dated 9/8/22.2. Impaired physical mobility and dependent on staff for care: ensure the call light is available, dated 4/23/24.During a concurrent observation and interview…

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 three sampled residents (Resident 1, Resident 2, and Resident 3) received appropriate PASSR (Preadmission Screening and Resident Review - a federal requirement ensuring individuals with serious mental illness, intellectual disabilities, or related conditions are not inappropriately placed in Medicaid-certified nursing facilities and receive appropriate services) evaluations. This failure excluded each Resident from a complete mental health evaluation for appropriate facility placement, and non-receipt of available mental-health resources from the California Department of Developmental Services (DDS). Findings: During a record review of Resident 1's, admission Record, printed 5/6/25, it indicated Resident 14 was originally admitted to the facility on [DATE], with diagnoses including toxic encephalopathy (a brain disorder caused by exposure to toxic substances, leading to altered mental status and other neurological symptoms), post-traumatic…

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 face-to-face physician visits at least once every 60 days for three sampled residents (Resident 1, Resident 2, and Resident 3). This deficient practice had the potential to result in a decline in medical, health or psychosocial condition and lead to a delay in necessary care, treatment and services. Findings: A review of Resident 1 ' s, admission Record, dated 5/6/25, indicated Resident 1 was initially admitted to the facility on [DATE], with diagnoses including acute respiratory failure (a life-threatening condition where the lungs cannot adequately provide oxygen to the blood or remove carbon dioxide), post-traumatic stress disorder (a mental health condition that can develop after experiencing or witnessing a traumatic event. Symptoms include intrusive memories, nightmares, flashbacks, avoidance of triggers, negative thoughts and feelings, and hypervigilance), anxiety disorder (excessive worry and fear that significantly interferes with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Licensed Nurses (LNs) administered medications to residents per physician's order for two residents (Resident 1 and Resident 2) of four sampled residents when LNs administered medications late. This finding had the potential to result in serious side and adverse effects to the residents receiving late medications. Findings: A review of an admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included palliative care (specialized medical care for people with serious illnesses which is focused on relieving suffering and improving quality of life) and malignant neoplasm of skin (skin cancer). A review of a facility document titled, Medication Audit Admin Report, dated 3/1/25 to 3/31/25 indicated: -On 3/1/25, propranolol (medication used to treat tremors) 60 milligrams (mg, a unit of measurement) was scheduled to be given at 12 p.m. It was documented as administered at 4:14 p.m. -On 3/1/25, methadone…

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 adequate staffing with appropriate competencies was maintained to meet the physical needs of the residents, as evidenced when treatments for wound care were not provided as ordered by the Physician for four of nine sampled Residents: Resident 1, Resident 2, Resident 3 and Resident 4. This failure had the potential for delaying the healing of the wounds and increasing the risk for the wounds to become infected. Findings: During a review of clinical records on 2/20/25, Resident 1's Medical Doctors, Order Summary Report for 2/2025, had the following orders for wound care: 1. Cleanse left breast malignant wound with wound cleanser and pat dry; apply skin barrier cream every day shift for wound care per (wound specialist) instructions. Start date was 8/22/24. 2. Dakins (1/4 strength) External Solution (Sodium Hypochlorite) Apply to coccyx topically every day shift every Mon, Wed, Fri for pressure injury Cleanse with Dakins solution, pat dry, apply calcium alginate to wound bed, cover with mepilex dressing or equivalent.…

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 allegation of abuse was reported within the required timeframe for two residents (Resident 2 and Resident 3) of two sampled residents when the facility reported an allegation of abuse to the California Department of Public Health (the Department) three days after the incident occurred. This failure decreased the facility's potential to ensure resident safety and cause a delayed response by enforcement agencies. Findings: A review of the facility's document titled 5-Day Conclusion Resident to Resident Altercation dated 11/22/24 indicated a Certified Nursing Assistant (CNA) witnessed Resident 3 hitting Resident 2 on the face with a shoe on 11/15/24 at approximately 11:30 p.m. During an interview on 1/7/25 at 2:15 p.m., the Director of Staff Development (DSD) stated it was the facility ' s policy to report an allegation of abuse to the Department within two hours. The DSD confirmed the 11/15/24 allegation of suspected abuse had not been reported to the Department until 11/18/24. During an interview on 1/8/25 at 2:10…

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 did not maintain a safe and functional environment when the transition strip (flooring strip designed to smooth out the junction of different flooring types) at two of four doorways was in the wrong position to make a smooth surface at the threshold, (the bottom of the doorway.) The two doorways were at room [ROOM NUMBER] and the 1st shower room on the same hall. This failure resulted in Resident 1 falling at the doorway of room [ROOM NUMBER] and breaking her arm. This failure had the potential to cause Resident 1 to fall again, as well as cause other residents, staff, and the public, (due to unsafe and poorly maintained flooring,) to fall. Findings: During a review of Resident 1's medical records on 11/20/24, Resident 1's Progress note dated 9/9/24 at 15:37 and titled IDT Progress Notes - Falls documented that Resident 1 had a fall on 9/7/24 at 2:50 p.m. IDT Progress note indicated resident was walking/ambulating out of her room, without her…

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

Based on interviews and record reviews, the facility failed to ensure that one of three sampled residents, Resident 1, was free from a significant medication error when an extra dose of Oxycodone ( Oxycodone belongs to a class of drugs known as opioid analgesics. It works in the brain to change how your body feels and responds to pain) HCL (Hydrochloride) 5 mg (milligrams) was administered by Licensed Nurse A without a physician's order. This failure had the potential to result in an adverse (having a negative or harmful effect on something) reaction to Resident 1 that could affect his health and safety. Findings: A review of Resident 1's Order Summary Report, dated 2/15/24, indicated he had an order for Oxycodone HCL 5 mg, give 1 tablet by mouth every 6 hours as needed for pain, only use when non-narcotic options are ineffective. A review of Resident 1's MAR (Medication Administration Record) indicated on 2/11/24, he was given Oxycodone HCL 5 mg at 6:30 a.m. and 10 a.m. The MAR indicated that the dose given at 10 a.m. was for a one-time dose only ordered on 2/11/24. A review of…

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

Based on interview and record review, the facility Quality Assurance and Performance Improvement (QAPI) committee failed to identify and include repeated resident concerns into their current QAPI programs. This failure resulted in recurrent resident complaints of missing laundry items, long call light response times, and late medications. Findings: During an interview on 5/31/23 at 3:59 p.m., Advocate A stated residents have had repeated complaints related to late medications, missing laundry, and long wait times for call lights. Advocate A stated while residents were comfortable expressing grievances, they felt the facility offered temporary fixes that do not fully resolve their issues. Advocate A stated this lack of full resolution resulted in reoccurrences of resident complaints. During an interview on 6/1/23 at 3:19 p.m., Resident 3 stated that while some resident grievances get resolved, some problems keep happening over and over and over again. Resident 3 stated it was this reoccurrence that makes residents feel like the facility was not really fixing the issues. A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure residents had a clean and sanitary environment when two of two resident shower rooms were kept in poor condition. This failure resulted in three of four residents (Residents 1, 2, and 3) to verbalize disgust over the use of said rooms and had the potential for all other 61 residents for unhappiness and decreased level of self-worth. Findings: A review of Intake Information, dated 05/22/2023, revealed resident complaints of dirty shower rooms at the facility. During an observation on 6/1/23, at 1:21 p.m., discolored wall and floor tiles were seen in the South Wing Hall shower room. Black strips of anti-skid tape were peeling from the floor. During an interview on 6/1/23, at 1:44 p.m., with Resident 1, Resident 1 stated the shower rooms were disgusting and filthy. During an interview on 6/1/23, at 2:20 p.m, with Resident 2, Resident 2 stated the shower rooms were gross and needed to be deep cleaned. During an observation of the…

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

Based on interviews and record reviews, the facility failed provide pharmaceutical services that meet the needs of the two of four sampled residents (Residents 1 and Resident 2) when: a. Resident 1 had four medications, including two doses of methadone (used for pain control), and b. Resident 2 had 11 medications, including four doses of trazodone (used to help with inability to sleep), that were administered late during a sample period of seven days. This failure resulted in both residents verbalizing feelings of anger and anxiety, and increased Resident 1 ' s potential to experience unmanageable pain, and for Resident 2 to have decreased quality sleep. Findings: During an interview on 6/1/23, at 1:44 p.m., Resident 1 angrily stated her medications were always given late, at times even up to two hours. Resident 1 stated she needed her methadone for her chronic pain, and it made her anxious especially when her pain medications were given late. During a review of Resident 1 ' s Medication Admin Audit Report, (MAAR), dated 05/26/2023-06/02/2023, the MAAR indicated the following late…

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 (1) failed to ensure 4 of 5 sampled residents (Residents 8, 12, 19, and 33) reviewed for physician visits had monthly, in person, physician visits during the first 90 admission or at least every 60 days thereafter; and (2) failed to ensure 21 of 52 residents (Residents 3, 6, 8, 9, 12, 13, 18, 19, 21, 22, 23, 27, 28, 29, 32, 33, 34, 39, 41, 43, and 45) (40% of the facility residents) had an assigned physician who saw them at the facility when the physician managing the care of these residents (Medical Doctor H) was based 600 miles away in southern California and did not visit the facility. These failures resulted in Residents 8, 12, 19, and 33's care not being supervised by a physician in the frequency and format required and placed Residents 3, 6, 8, 9, 12, 13, 18, 19, 21, 22, 23, 27, 28, 29, 32, 33, 34, 39, 41, 43, and 45 at risk of not having their care supervised in the frequency and format required. Findings: A review of the census sheet for 7/18/22…

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 it employed nursing staff with appropriate competencies and skills to care for facility residents when: (1) The facility failed to provide initial orientation, initial and annual competency/skills checks, and regular performance evaluations to six of six nursing staff sampled for verification of orientation, training and competencies: three Licensed Nurses (Licensed Nurses A, F and G) and three Certified Nursing Assistants (CNAs B, N and O); and (2) The facility failed to ensure it had an ongoing and functional staff orientation and training program when (a) the staff whose job description was to direct the facility's staff orientation, training and competencies, the Director of Staff Development (DSD), worked part-time, also worked as a nursing supervisor, and as a floor nurse, and indicated her only responsibilities were to ensure staff physical exams and tuberculosis screening were current; and (b) the residual responsibility for staff…

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 implement an effective infection control program when staff were not wearing masks inside the facility, staff touched their mask after touching a mask contaminated with SARS-CoV-2 (the virus that causes COVID-19), and housekeeping staff entered rooms of residents on contact and droplet precautions without performing hand hygiene between rooms, without wearing the personal protective equipment (PPE) required, and using one rag to clean multiple rooms. This failure potentially caused spread of COVID-19 in a vulnerable population in a facility experiencing an outbreak of COVID-19. Findings: During an observation and concurrent interview on 5/26/22 at 9:50 a.m., a tour of the facility was conducted with Nurse Consultant B. The facility had a Yellow Zone for residents who had been exposed to COVID-19 and a Red Zone for residents who had tested positive for COVID-19. At the entrance to the Red Zone, Licensed Nurse C stated she had 15 residents assigned to her, and the other nurse in the Red Zone also had 15…

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 notify the physician of the positive test results for four days for one of 37 residents (Resident 1) who tested positive for COVID-19 during the first 10 days of a facility outbreak. This resulted in a delay of four days in starting the antiviral for a vulnerable resident with comorbities. Findings: During a record review and concurrent interview on 5/26/22 at 1:15 p.m., Director of Nursing (DON) described the symptoms experienced by each of the residents on the line list for the facility's COVID-19 outbreak. The line list, dated 5/25/22, indicated Resident 1 tested positive for COVID-19 on 5/20/22, along with six other residents on that day. DON stated Resident 1 had respiratory symptoms at his baseline and that he was experiencing an increased cough and runny nose. During an interview on 5/27/22 at 11:30 a.m., Licensed Nurse J stated residents' positive COVID tests were reported to upper management including the DON. When asked who reported the positive COVID test results to the resident's physician, Licensed Nurse J…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide a clean, sanitary, and homelike environment to four of five residents when the facility (1) failed to ensure the bathrooms of two of three sampled residents (Residents 25 and 26) were sufficiently cleaned and (2) failed to ensure three of three resident rooms (Rooms 21, 24 and 25 - occupied by Residents 24 and 201) had window screens that fully covered the window frames without gaps that could serve as an entry point for insects. These failures resulted in Residents 25 and 26 using filthy bathrooms, and flies and spiders coming into rooms of Residents 24 and 201, and had the potential for flies, spiders and other insects to come into the facility. Findings: 1. During a review of Resident 25's, admission Record, dated 7/1/21, indicated Resident 26 was admitted to the facility on [DATE] with a history of high blood pressure, blindness in both eyes, traumatic brain injury (brain dysfunction caused by an outside force, usually impact…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide showers as scheduled for two (Resident 26 and 43) out of 4 sampled residents. The failure had the potential to resulted in residents being dirty and unkempt. Findings: 1. During a review of Resident 26's, admission Record:, dated 6/23/19, indicated Resident 26 had been admitted to the facility on [DATE] with a history of chronic kidney disease, immunodeficiency (a state in which the immune system's ability to fight infectious disease and cancer is compromised or absent) and obstructive sleep apnea (intermittent air flow blockage during sleep). During a review of Resident 26's Quarterly MDS (Minimum Data Set, a clinical assessment process which provided a comprehensive assessment of resident's functional capabilities and helped staff identify health problems), dated 3/23/22, indicated Resident 26 had a BIM (Brief Interview of Mental Status) score of 12, indicating mild mental or cognition impairment. During an interview on 7/19/22…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide adequate respirator care to three (Resident 17, 26 and 7) out of four sampled residents when the facility could not determine how continuous positive airway pressure (CPAP) machines were maintained for residents who required them. These failures had the potential result in being uncomfortable to the residents due to missing additives and potential respiratory infections by tubing not being maintained or replaced appropriately. Findings: 1. During a review of Resident 17's, admission Record, dated 6/27/14, indicated Resident 17 was admitted to the facility on [DATE] with a history of chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), high blood pressure and generalized muscle weakness. During a concurrent observation and interview on 7/18/22 at 2:57 p.m., Resident 17 was observed taking a nap in his bed with his clothes on and wearing his CPAP machine (face type mask…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure its medication error rate was not greater than 5% when 12 medication errors were observed during 26 medication observations of two of six residents (Residentt 6 and 7), resulting in a medication error rate of 46%, when: (1) Resident 7 was administered 10 medications on 7/20/22 outside their prescribed scheduled times, as follows: (1) Insulin Lispro 2 units (for blood sugar control) due at 7 a.m. and given at 11:10 a.m.; (2) Metformin 1000 mg [milligrams] (for blood sugar control) due 7:30 a.m. and given at 11:10 a.m.; (3) Eliquis 5 mg (a blood thinner) due 8 a.m. and given at 11:10 a.m.; (4) Albuterol Sulfate Inhaler (for lung function) due at 8 a.m. and given at 11:10 a.m (5) Lisinopril 2.5 mg (for blood pressure) due at 9 a.m. and given at 11:10 a.m.; (6) Methadone 5 mg (for pain) due at 9 a.m. and given at 11:10 a.m.; (7) Lidocaine Patch 5% (for pain) due at 9 a.m. and given at 11:10 a.m.; (8) Diazepam 5 mg (for pain) due at 9:…

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 their policy on antibiotic stewardship by not replacing the Infection Preventionist. This failure resulted in residents not being tracked and monitored regarding their antibiotic usage and efficacy creating potential inappropriate use of antibiotics and potential resistance to antibiotics. During a telephone interview on 7/26/22 at 12:35 p.m., with Infection Preventionist (IP), she stated as of 4/28/22, she was part-time, working one hour a day to assist in reporting data for the facility. IP was asked who was in charge in antibiotic stewardship and she stated she was until 4/28/22 but did not know who had taken over the role. During an interview on 7/26/22 at 1:10 p.m. with Director of Nursing (DON), she stated there was corporate person who was assisting the facility with infection prevention and control, but that employee was on vacation and unable to be interviewed. DON stated another corporate person who was also assisting the facility in infection prevention and control would be able to answer…

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 employ an infection preventionist (IP) who worked at least part-time. This failure resulted in minimal oversight of the infection prevention and control program during an outbreak of COVID-19 in the facility. Findings: During an observation and interview on 5/26/22 at 9:35 a.m., the facility front door was propped open and no one was at the screening table (table set up to document persons entering the building, check temperature for fever, and screen for signs or symptoms of COVID or potential COVID exposure). Nurse Consultant B came to the screening table and stated she had just arrived. Nurse Consultant B stated she was texting the administrator and the director of nursing to inform them of this surveyor's arrival. Nurse Consultant B confirmed Administrator and Director of Nursing (DON) were not at the facility. Nurse Consultant B stated she did not work at the facility, she worked for a shell company. During an observation and concurrent interview on 5/26/22 at 9:50 a.m., a tour of the facility was…

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

Based on interview and record review, the facility failed to provide training on abuse prevention and reporting to its nursing staff (licensed nurses and certified nursing assistants) when (1) only one quarter of its nursing staff (12 of 47 staff) received annual training on abuse prevention and reporting and when (2) six of six nursing staff (Licensed Nurse A and Certified Nursing Assistants H, P, W, Y and Z) could not correctly answer basic questions about abuse prevention and reporting. These failures placed the facility residents at risk of abuse. Findings: During an interview on 07/21/22, at 2:36 p.m. the Director of Payroll (DP) provided a list of all the nursing staff - licensed nurses and certified nursing assistants - employed by the facility including registry, full-time and part-time. A review of this list indicated 15 Licensed Nurses and 32 Certified Nursing Assistant (CNAs). During an interview on 7/26/22, at 2:46 p.m., the Director of Nursing (DON) and the Director of Staff Development (DSD) stated they were responsible for abuse prevention and reporting training. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report to the Department one allegation of physical abuse for one of two sampled residents (Resident 32). This failure prevented the Department from timely investigating the abuse allegation involving Resident 32. Findings: During a review of Resident 32's, admission Record, dated 7/29/16 indicated Resident 32 was admitted to the facility on [DATE] with a history of Parkinson's' disease (a disorder of the central nervous system that affects movement, often including tremors), paranoid disorder (an unrealistic distrust of others or a feeling of being persecuted), schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly) and high blood pressure. During a review of Resident 32's Quarterly MDS (Minimum Data Set, a clinical assessment process which provides comprehensive assessment of resident's functional capabilities and helps staff identify health problems) dated 2/21/22, indicated Resident 32 had a BIMS (Brief…

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 provide care and services for one of one resident (Resident 199) with an indwelling urinary catheter (Foley Catheter) (a flexible tube inserted into the bladder used to drain urine) when, during a period of 30 days, from Resident 199's admission to the facility with a Foley catheter on 6/28/22 until 7/27/22, the facility (1) did not create or implement a Foley catheter care plan for Resident 199; (2) did not monitor Resident 199 for signs and symptoms of urinary tract infections; and (3) did not provide Foley catheter care to Resident 199 every shift, as ordered. These failures placed Resident 199 at risk of developing a urinary tract infection. Resident 199 developed a urinary tract infection on 7/23/22. Findings: A review of Resident 199's Facesheet indicated he was admitted to the facility on [DATE] with a primary diagnosis of spinal cord injury and additional diagnoses including history of falling, generalized muscle weakness, bed…

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 2 of 2 gas supplied cooking units, were maintained in working order which had the potential to cause property damage, injury or death. Findings: During an initial kitchen tour, on 4/8/19, at 8:29 a.m., observed a gas range and oven combination. Observed 8 cylindrical rods approximately one centimeter in diameter protruding from the front of the oven portion directly underneath the range. Noted a faint odor detected when approximately six inches away from the top of the range. Two pictures taken of the range and oven. At 8:32 a.m., Observed a range, grill top, oven combination. Observed white powdery substance on the burner of the range. Two pictures taken. No audible sound coming from the exhaust hoods above either range. During an interview with the Dietary Manager (DM), on 4/8/19, at 8:52 a.m., she stated the kitchen staff only use the oven portion of the range oven combination. The DM confirmed that the rods were where the knobs to turn the burners on the range would attach. The DM explained it was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to individualize plans of care of 2 of 4 sampled Residents (Resident 58 and Resident 52) when: 1. The Careplan for Resident 58 failed to provide individualized interventions to reduce the risk of falls, which resulted in the Resident having five falls in a three-month period from 1/1/19 to 4/1/19, and resulted in multiple unwitnessed falls one with injury. (Cross Reference F689) 2. The Careplan for Resident 52, there was no care plan addressing non-compliance with repositioning before the pressure ulcer developed and the intervention for encouraging independent repositioning was not performed. (Cross Reference 686). This failure resulted in Resident 52 developing a Stage 2 pressure ulcer and at risk for developing another pressure ulcer. Findings: 1. During an interview with Resident 58 alone in her room on 04/09/19 at 3:55 p.m.: Have you had any falls? I did Can you tell me what happened? I don't remember During an interview with Unlicensed…

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, interview and record review, the facility failed to develop and implement new employee competency and ongoing competency assessment training program for Certified Nursing Assistants (CNAs). This failure had the potential for inappropriate and unsafe resident care resulting in potential injury or death. Findings: During a concurrent review of CNA Core Clinical Competencies and interview with Manager G on 4/9/19 at 2:43 p.m. indicated unlicensed staff had been deemed competent by the completion of the form. Manager G stated she used the form in documenting competencies with unlicensed staff members. Manager G indicated a check mark in the Yes column would signify the unlicensed staff member was competent to perform the task on residents. Manager G stated the form did not specify how the unlicensed staff member's clinical competency skills were assessed or measured, but she would ask the newly hired unlicensed staff member to verbalize how they would complete the task. Manager G indicated for instance under one of the competencies titled, Adult Brief Application…

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 necessary dental care for 6 residents (Resident 18, 29, 34, 52, 213 and 214) which had the potential to result in pain, impaired chewing capability, and further deterioration of oral health. Findings: During an interview with the Social Services Director (SSD), on 4/9/19, at 3:07 p.m., she described the process for dental services in the facility. The SSD stated Residents in need of dental services are transported to their personal dentist or a local dental clinic. The SSD stated that the facility had 2 vans with wheelchair lifts to transport residents to appointments. The SSD was unable to explain how residents that were not healthy enough to be transported were getting dental services. During an interview with the SSD, on 4/9/19, at 3:21 p.m., she stated that a mobile dental clinic provided services on 7/18 and was scheduled to return 5/19. The SSD explained how the facility ensured dental care was provided for newly admitted residents. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an effective Antibiotic Stewardship program was present and functioning, including promoting the appropriate use of antibiotics and consistent monitoring of antibiotic use to improve resident outcomes and reduction of antibiotic resistance, according to facility policy and procedure (P&P). This failure had the potential for inappropriate us of antibiotics resulting in adverse events associated with antibiotic use and subsequent antibiotic resistance (drugs designed to kill bacteria are no longer effective and bacteria are able to multiply). Findings: 1. During an interview and concurrent document review on 4/12/19 at 9:53 a.m., with Manager F, she indicated in the monthly Infection Control binder under January 2019, Resident 44 had been prescribed Levaquin for an upper respiratory infection as indicated by the physician order and monthly pharmacist review. The medication was indicated for treatment based on empirical (medical treatment based on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the accuracy of assessment for one of one resident reviewed for change of condition out of 17 sampled residents (Resident 35) when the Minimum Data Set (MDS-a resident assessment instruments-core set of screening, clinical, and functional status elements, including common definitions and coding categories, which forms the foundation of a comprehensive assessment for all residents) did not reflect Resident 35 was receiving hospice service(comfort care for terminally ill people). This failure resulted in three MDS with incorrect entries putting resident at risk for not receiving services. Findings: Review of the facility Matrix for Providers (used to identify pertinent care) received on 4/8/19, indicated the facility was providing hospice services for Resident 35. Review of the Minimum Data Sets dated 5/22/18 and 11/19/18 indicated Resident 35 was not receiving hospice service. The MDS dated [DATE] indicated Resident 35 was receiving hospice care.…

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

Based on observation, interview, and record review, the facility failed to provide care to prevent pressure ulcer (a localized damage to the skin usually over a bony prominence or related to a medical or other device) from developing for 1 of three residents reviewed for pressure ulcer out of 17 sampled residents (Resident 52). This failure resulted to Resident 52 developing stage 2 pressure ulcer (sore digs deeper below the surface of your skin) on her coccyx (tailbone/buttocks region). Findings: Review of the Facesheet (demographic data) indicated the facility admitted Resident 52 to the facility on 2/15/19 with a primary diagnoses of Pneumonia (lung infection), malaise, diabetes mellitus (high blood sugar), and abnormalities with gait and mobility. Review of the Resident Baseline Evaluation dated 2/15/19, indicated Resident 52 had blanchable redness (skin loses redness with pressure. Non-blanchable is a stage 1 pressure ulcer, redness of intact skin ulcer in which skin does not lose redness with pressure) on her coccyx area. Review of the Short-term Non-Pressure Ulcer due to thin…

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 had a 7.14% medication error rate when two medication errors out of 28 opportunities were observed during medication passes for one of seven residents (Resident 215). These failures had the potential to compromise the residents' medical health. Findings: During a medication pass observation and concurrent interview for Resident 215 on 4/11/19, at 9:24 a.m., Licensed Nurse L prepared and verified four medications: Docusate sodium (stool softener), Clopidogrel (prevent blood clots) and Glimepiride and Metformin (both used to treat high blood sugar) for Resident 215. At 9:28 a.m., Resident 215 took all four medications. When asked what time Resident 215 ate breakfast, Resident 215 stated, just finish eating a while back. During an interview on 4/11/19, at 9:29 a.m., when asked how medications to be given with meals are given, Licensed Nurse L stated, I usually catch him (Resident 215) a little early in the morning. I try to get close as I can…

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 label drugs and biologicals in accordance with currently accepted professional principles when one of two vials of Tuberculin (used in skin test to aid diagnosis of tuberculosis (TB) infection in persons at increased risk of developing active disease.) did not have an opened date label. This failure had the potential for licensed nurse to administer expired drugs and biologicals to residents. Findings: During a medication storage observation and concurrent interview on 4/11/19 at 5:01 p.m., Licensed Nurse J verified the medication refrigerator contained one opened vial of Tuberculin with no opened date label. Review of the Tuberculin package insert (a document included in the package of a medication that provides information about that drug and its use.) taken out of the opened vial's packaging indicated, Vials in use for more than 30 days should be discarded. The facility policy and procedure titled Storage of Medication dated 2007, indicated Refrigerated medications are kept in closed and labeled containers…

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.