Kei-Ai South Bay Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to: 1. Ensure a peripherally inserted central catheter ([PICC]- a long thin tube inserted into the upper arm to give medication) dressing was labeled with a date, time and initials for one of one sampled resident (Resident 77). This deficient practice had the potential for the PICC line insertion site to develop an infection and/or hospitalization for Resident 77.Findings: During a review of Resident 77's admission Record, the admission Record indicated Resident 77 was admitted to the facility on [DATE]. Resident 77's diagnoses included sepsis (a life-threatening blood infection), methicillin-resistant staphylococcus aureus (MRSA - a bacteria that does not respond to antibiotics), and paraplegia (loss of movement and/or sensation, to some degree, of the legs). A review of Resident 77's Minimum Data Set ([MDS], a standardized assessment and care planning tool), dated 1/13/2026, the MDS indicated the resident was assessed to have clear…

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: 1. Obtain physician orders prior to initiating low air loss (LAL) mattress therapy for two of eight sampled residents (Residents 2 and 14). This deficient practice had the potential to result in unnecessary treatment and adverse outcomes. Findings:a.During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnoses included dementia (a progressive state of decline in mental abilities), sepsis (a life-threatening blood infection), and encephalopathy (any condition that causes the brain to function abnormally, leading to mental changes like confusion, memory loss, personality shifts, or drowsiness). During a review of Resident 2's History and Physical (H&P), dated 12/1/2025, the H&P indicated Resident 2 did not have the capacity to make decisions. During a review of Resident 2's Minimum Data Set ([MDS], a standardized assessment and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to: 1. Ensure one of seven sampled residents (Resident 99) eye drop medication Timolol (medication to treat high pressure inside the eye) was properly stored. This deficient practice of leaving the eye drop medication Timolol at bedside had the potential for the medication to be used by other residents.During a review of Resident 99's admission Record ([Face Sheet] front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 99 was admitted to the facility on [DATE]. Resident 99's diagnoses hemiplegia (paralysis affecting one side of the body), chronic obstructive pulmonary disease ([COPD]- a chronic lung disease causing difficulty in breathing) and anxiety (an uneasy feeling of discomfort, apprehension, or dread to a non-specific or unknown threat). During a review of Resident 99's history and physical (H&P), dated 7/17/2025, the H&P indicated Resident 99 had the capacity 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, interview, and record review, the facility failed to ensure 3 of 4 outside trash bin lids were completely closed. This failure had the potential to result in odors attracting pests and scavengers (organisms that feed on dead matter) to the trash bins.Findings:During an observation on 1/20/2026, at 1:43 p.m., one trash bin had both covers open and another trash bin had one cover partially opened and no staff were in the immediate area. During an interview on 1/20/2026, at 1:44 p.m., with DS3, DS3 stated, trash cans should be covered and if trash is uncovered rain and animals can get into the trash. During an interview on 1/23/2026 at 9:10 a.m., with the DSS, the DSS stated that the lids on the trash bins should be closed at all times. During a review of the facility's policy and procedure (P&P) titled, Food-Related Garbage and Refuse Disposal dated October 2017, the P&P indicated, all garbage and refuse containers are provided with tight-fitting lids or covers and must be kept covered when stored or not in continuous use.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the urinal bottle (handheld container for pee) for Resident 113 had a cover to prevent spillage of urine. This failure had the potential to result in urine spilling onto staff or Resident 113 during care.Findings: During a review of Resident 113's admission Record, dated 1/15/2026, the admission Record indicated Resident 113 has diagnoses for Cellulitis (a common, potentially serious bacterial skin infection) of the right lower limb, Local infection of the skin and subcutaneous (beneath the skin) tissue, and sepsis (a life-threatening medical emergency caused by the body's overwhelming, dysfunctional immune response to an infection, leading to tissue damage, organ failure, and potential death). During a review of Resident 113's Order Summary Report, dated 1/15/2026, the Order Summary Report indicated Resident 113 was on a Regular Diet, and on a 5150 hold due to episodes of agitation and verbally aggressive towards staff. During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents' (Resident 1) transfer summary was completed, and telephone report was called to the receiving facility, prior to discharge on [DATE], as indicated in the facility's policy and procedure (P&P) titled, Discharging the Resident. This failure caused Resident 1's discharge to the independent living facility (ILF, a community for active seniors who want to maintain their independence but desire the benefits of a maintenance-free lifestyle and community amenities, such as dining, fitness centers, housekeeping, and social activities) on 8/20/2025, who could not fully provide and accommodate the resident's needs and had the potential to affect the resident's highest practicable physical, mental and psychosocial well-being.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including diabetes mellitus (DM-a disorder…

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 staff supervision for 2 of three sampled residents (Resident 1 and 2) by failing to ensure Resident 1 and Resident 2 were separated immediately by staff when Resident 2 was verbally aggressive towards Resident 1.This failure resulted in Resident 2 hitting Resident 1 on the left side of the face. Findings: During a review of Resident 1's admission Record (Front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included end stage renal disease ([ESRD] - irreversible kidney failure) on hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidneys have failed), chronic obstructive pulmonary disease ([COPD] - a chronic lung disease causing difficulty in breathing), and Diabetes Mellitus ([DM] - a disorder characterized by difficulty in blood 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one out of three sampled residents (Resident 1) had an accurate resident assessment (the process of systematically evaluating a resident's needs, strengths, and preferences to promote quality of life) on the Minimum Data Set ([MDS]- resident assessment tool) assessment for wandering (a resident tendency to move about aimlessly repeatedly). This deficient practice of not accurately documenting on the MDS of Resident 1 wandering behavior placed the residents at risk of not receiving accurate treatment Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 1 diagnoses Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), anxiety (a vague, uneasy feeling of discomfort or dread), and dementia (a progressive state of decline in mental abilities). During a review of Resident 1's History and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to place the call light buttons for 4 of 6 sampled residents (Residents 2, 4, 5 and 6), within their reach. This deficient practice placed Residents 2, 4, 5, and 6 at risk for not being able to call for help when needed and can result to needs not being attended to timely. This deficient practice had the potential to cause falls, other injuries, including hospitalization and death. Findings: During an inspection of the facility, on 5/16/25 at 10:45 am, the call light buttons in each residents ' room were inspected along with the Assistant Director of Nursing (ADON) for functioning and placement. Resident 2, the call light button was observed at the head of Resident 2 ' s bed, behind the pillow, Resident 2 could not reach the call light button. Resident 4, the call button was observed on the floor away from Resident 4 ' s reach. Residents 5, and 6, the call light button was on the bed away from Resident ' s reach. a). During 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 interview, and record review, the facility failed to follow its policy and procedure (P&P) titled, Transfer and Discharge Notice, when three of three residents (Resident 1, 2, 3) and their representatives did not receive written notification of transfer after transfer to the general acute care hospital (GACH). This failure had the potential for Resident 1's, Resident 2's, and Resident 3's representatives to not know their transfer rights and destination of the residents' transfers. Findings: 1. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. The admission Record indicated Resident 1 had a history of subdural hematoma (a collection of blood outside of a blood vessel between the skill and brain). The admission Record indicated Resident 1 had a responsible party. During a review of Resident 1's History and Physical (H&P), dated 7/27/2024, the H&P indicated Resident 1 did not have the capacity to make medical decisions due…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) titled, Physician Services, which indicated physicians must perform the initial face-to-face visit, sign admitting physician orders, and perform alternating visits with a non-physician practitioner (NPP), for one of three residents (Resident 1). This failure had the potential for Resident 1 to not be thoroughly assessed, not receive safe and adequate care. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. The admission Record indicated Resident 1 had a history of subdural hematoma (a collection of blood outside of a blood vessel between the skill and brain), end stage renal disease (ESRD-irreversible kidney failure) with dependency on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), and multiple myeloma (blood cancer).…

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: 1. Ensure one out of seven residents (Resident 73) had a privacy bag for the indwelling catheter (a device that is inserted into the bladder that collects and drain urine). This deficient practice of not covering the indwelling catheter had the potential to effect Resident 73's dignity. Findings: During a review of Resident 73's admission Record ([Face Sheet] front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 73 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 73's diagnoses included paroxysmal atrial fibrillation (irregular heartbeat that causes blood to pool in the heart), benign prostatic hyperplasia (a non-cancerous enlargement of the prostate gland), retention of urine (a condition that makes it difficult or impossible to empty the bladder), and extrapyramidal movement disorder (a condition that involve impaired motor…

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: 1. Ensure one out of seven sampled residents (Resident 45) had the call light (a button or device that a patient can press to signal a nurse or healthcare provider that they need assistance) within reach. This has the potential for the resident's needs will not be met promptly. Findings: During a review of Resident 45's admission Record ([Face Sheet] front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 45 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 45's diagnoses included heart failure (a clinical syndrome where the heart can't pump enough blood to the body), acute myocardial infarction (a sudden and severe blockage of a coronary artery that leads to the death of the heart muscle tissue due to lack of oxygen), and [NAME] syndrome (a condition that causes the colon to suddenly expand without a mechanical blockage). During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to: 1. Ensure one out of seven sample residents (Resident 144) had trimmed fingernails. This failure of not properly trimming Resident 144's fingernails had the potential to cause skin breakdown (a tear, blister, or cuts of the skin with the destruction of tissue and discomfort). Findings: During a review of Resident 144's admission Record ([Face Sheet] front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 143 was admitted to the facility on [DATE]. Resident 143's diagnoses included chronic obstructive pulmonary disease ([COPD]- a chronic lung disease causing difficulty in breathing), respiratory failure (when the body's respiratory system is unable to exchange oxygen and carbon dioxide properly), and pleural effusion (a condition where too much fluid builds up between the lungs and the chest cavity). During a review of Resident 143's History and Physical (H&P), dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to: 1. Ensure one out of seven sampled residents (Resident 84) the low air loss ([LAL] a mattress that helps prevent and treat pressure injuries) mattress had the correct settings. This deficient practice of not having the correct LAL mattress settings had the potential for Resident 84 to have skin breakdown (damage to the skin or underlying tissue caused by a loss of blood flow). Findings: During a review of Resident 84's admission Record (Face Sheet), the Face Sheet indicated Resident 84 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 84's diagnoses included encephalopathy (a medical condition where brain function is impaired, leading to symptoms like confusion, memory loss, and personality changes), pressure ulcer (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence), and chronic obstructive pulmonary disease ([COPD] a chronic lung disease causing…

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: 1. Ensure one out of seven sampled residents (Resident 143) to follow physician orders for oxygen therapy (a medical treatment that provides extra oxygen to a patient through a mask or nasal cannula). This failure had the potential of the resident not receiving appropriate medical care. Findings: During a review of Resident 143's admission Record ([Face Sheet] front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 143 was admitted to the facility on [DATE]. Resident 143's diagnoses included chronic obstructive pulmonary disease ([COPD]- a chronic lung disease causing difficulty in breathing), respiratory failure (when the body's respiratory system is unable to exchange oxygen and carbon dioxide properly), and pleural effusion (a condition where to much fluid builds up between the lungs and the chest cavity). During a review of Resident 143's History and Physical (H&P),…

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: 1. Ensure blood pressure medication was administered in a timely manner for one of 7 sampled residents (Resident 36). This deficient practice had the potential to result in high blood pressure, dizziness, and a stroke. Findings: During a review of Resident 36's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 36 was originally admitted on [DATE] with a readmission date of 5/11/2024. The face sheet indicated Resident 36 had diagnoses which included atrial fibrillation (an irregular and often very rapid heart rhythm), atherosclerotic heart disease (a condition where plaque builds up in the arteries, narrowing them and reducing blood flow) and hypertensive heart disease (a group of heart problems that develop over time due to high blood pressure). During a review of Resident 36's Minimum Data Set (MDS- a federally mandated resident assessment tool), 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: 1. Ensure the medication error rate was less than 5% for two of 2 sampled residents (Resident 36 and resident 148). This deficient practice had the potential to affect the efficacy and side effects of the medications. Findings: During observation of medication administration with Cart 1 and Cart 2, the combined medication error rate was 6.67% with 2 mediation errors out of 30 opportunities. a. During a review of Resident 36's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 36 was originally admitted on [DATE] with a readmission date of 5/11/2024. The face sheet indicated Resident 36 had diagnoses which included atrial fibrillation (an irregular and often very rapid heart rhythm), atherosclerotic heart disease (a condition where plaque builds up in the arteries, narrowing them and reducing blood flow) and hypertensive heart disease (a group of 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: 1. Ensure medication was ordered from the pharmacy for one of 8 sampled residents (Resident 148). This deficient practice resulted in Resident 148 missing 9 doses and had the potential to result in resident exhibiting physical aggression, restlessness, and manic behavior. Findings: During a review of Resident 148's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 148 was admitted to the facility on [DATE]. The face sheet indicated Resident 148 had diagnoses which included psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), dementia (a progressive state of decline in mental abilities), urinary tract infection (UTI- an infection in the bladder/urinary tract) and dehydration (a dangerous loss of body fluid caused by illness, sweating, or inadequate intake). During a review of 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 observation, interview and record review, the facility failed to: 1. Ensure Tylenol suppositories (a rectal medication used to relieve mild to moderate pain from headaches or muscle aches and to reduce a fever) stored in a clear, Ziplock bag was labeled and dated in the Station 1 Medication Storage room. This deficient practice had the potential to result in medication errors. Findings: During a concurrent observation and interview, on 01/10/2025, at 9:17 a.m., with Licensed Vocational Nurse 3 (LVN 3), LVN 3 observed an unlabeled and undated clear Ziplock bag with 52 rectal Tylenol suppositories stored in the medication fridge. LVN 3 stated the Ziplock bag should had been labeled and dated with an open date and expiration date. LVN 3 stated the risk of storing an unlabeled bag of medication in the medication refrigerator could result in medication errors. LVN 3 stated there was no label on the bag. LVN 3 stated We don't know if the medication is expired, if it belongs to a resident or what the medication is. During an interview, on 01/10/2025, at 4:03 p.m., with 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: 1. Ensure dental services were provided for one of 7 sampled residents (Resident 35). This deficient practice had the potential to result in a delay in necessary dental care and services. Findings: During a review of Resident 35's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 35 was originally admitted to the facility on [DATE] with a readmission date of 07/19/2023. The face sheet indicated Resident 35's had diagnoses which included dementia (a progressive state of decline in mental abilities), dysphagia (difficulty swallowing), atrial fibrillation (an irregular and often very rapid heart rhythm), and pneumonia (an infection/inflammation in the lungs). During a review of Resident 35's Minimum Data Set (MDS- a federally mandated resident assessment tool), the MDS indicated Resident 35 cognitive skills was severely impaired. The MDS also 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 observation and interview the facility failed to change oxygen tubing in seven days for one out of five Residents (Resident 66). This deficient practice placed Resident 66 at risk for infection. Findings: During a review of Resident 66's admission Record (Face Sheet), the Face Sheet indicated Resident 66 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 66's diagnoses included chronic obstructive pulmonary disease (a medical condition that cause airflow blockage and breathing-related problems), heart failure (a medical condition that develops when the heart does not pump enough blood for your body's needs), and chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood). During a review of Resident 66's History and Physical (H&P), dated 12/7/2023, the H&P indicated Resident 66 does not have the capacity to understand and make decisions. During a review of Resident 66's Minimum Data Set ([MDS] a comprehensive assessment…

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 implement its policy and procedure (P&P) titled Change in Resident's Condition or Status for one of three sampled residents when the facility failed to notify a resident's representative within 24 hours of a significant change in Resident 1's health status. This failure resulted in a violation of Resident 1's rights. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and had a resident representative. Resident 1's diagnoses included history of multiple myeloma (blood cancer that decreases the ability to fight infection), type II diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), and end-stage renal disease (ESRD- irreversible kidney failure) with dependence on dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed). During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a care plan for one of three sampled residents (Resident 1) after a new wound was identified. This failure had the potential to result in Resident 1 not receiving appropriate care and developing an infection and further skin breakdown. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included history of multiple myeloma (blood cancer that decreases the ability to fight infection), type II diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), and end-stage renal disease (ESRD- irreversible kidney failure) with dependence on dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed). During a review of Resident 1's History and Physical (H&P), dated 7/27/2024, the H&P indicated Resident 1 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide one of three residents (Resident 1) with a physician-ordered computerized tomography scan (CT scan- an imaging test that helps detect diseases) and general surgeon referral. This failure had the potential to result in a delay in care and worsening of Resident 1's localized swelling and severe ascites (fluid buildup in the abdomen). Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included history of multiple myeloma (blood cancer that decreases the ability to fight infection), ulcerative colitis (chronic inflammation of the lining of the digestive tract) with rectal bleeding, and end-stage renal disease (ESRD- irreversible kidney failure) with dependence on dialysis (a treatment to cleanse the blood of waste and extra fluid artificially through a machine when the kidney(s) have failed). During a review of Resident 1's History and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement infection prevention precautions for one of three sampled residents (Resident 1) when Resident 1's wound dressing was soiled and not changed, and when one certified nursing assistant (CNA 1) did not wear required personal protective equipment (PPE) when providing care to Resident 1. These failures had the potential to result in contamination and infection of Resident 1's wound and spread of Resident 1's infection to other residents and staff members. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included history of multiple myeloma (blood cancer that decreases the ability to fight infection), type II diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), and end-stage renal disease (ESRD- irreversible kidney failure) with dependence on dialysis (a treatment…

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 document vital signs after treatment for shortness of breath, wheezing, vomiting, and sweating interventions were performed, for one of three sampled residents, (Resident 1). This failure had the potential for vital signs not taken, the necessary care and services Resident 1 would have needed not provided, and contributed to Resident 1 ' s death on [DATE] at 10:57 a.m. Findings: During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 1 ' s diagnoses included hydrocephalus (a condition in which fluid accumulates in the brain), diabetes mellitus (when the body is unable to control the amount of glucose in the blood), aphasia (a language disorder that affects a person ' s ability to understand and express written and spoken language), gastro-esophageal reflux disease ( a chronic condition that occurs when stomach contents…

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, and interview, the facility failed to ensure the licensed nurse performed hand washing or hand sanitizing in between changing to new pair of gloves, when wound care were performed for three of five sampled residents (Residents 2, 3, and 4). This deficient practice had the potential for cross contamination and to spread infection between resident which could result to delay in wound healing and wound infection. Findings: During an observation on 7/30/2024 at 8:55 a.m., in Resident 2's room, Resident 2 was observed on bed awake, and alert. Licensed Vocational Nurse 1 (LVN) 1 prepared the wound care supplies inside a plastic basket.LVN 1 was observed washed her hands, put on a pair of gloves then removed dressing from Resident 2's gastric tube site ([GT] a surgical opening on the abdomen, into the stomach for food and medication administration), then, LVN 1 applied a clean dressing on the GT site. LVN 1 then changed gloves and applied A&D ointment (skin moisturizer) on Resident 2's upper back…

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 develop a comprehensive care plan for one of three sampled residents (Resident 1) who was refusing to participate in Restorative Nurse Assistant (RNA) program due to pain. This deficient practice had the potential to result in unidentified interventions to address Resident 1 ' s refusal and negatively affect the resident ' s well-being. Findings: A review of Resident 1 ' s admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure (a condition when the lungs could not get enough oxygen into the blood), metabolic encephalopathy (brain disorder) and UTI. The admission Record indicated Resident 1 was discharged from the facility on 4/22/2022. A review of Resident 1 ' s History and Physical (H&P), dated 1/29/2022, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1 ' s Minimum Data Set ([MDS] a standardized assessment and care screening…

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 thoroughly assess and monitor an elevated skin (lump like) for an increase in size, for one of three sampled residents (Resident 1) according to the physician ' s order and the facility ' s Policy and Procedure (P&P). This deficient practice had the potential to result in a delay in necessary treatment and worsening of the skin condition/lump for Resident 1. Findings: A review of Resident 1 ' s admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure (a condition when the lungs could not get enough oxygen into the blood), metabolic encephalopathy (brain disorder) and UTI. The admission Record indicated Resident 1 was discharged from the facility on 4/22/2022. A review of Resident 1 ' s History and Physical (H&P), dated 1/29/2022, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1 ' s Minimum Data Set ([MDS] a standardized…

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 implement proper pain management to one of three sampled residents, (Resident 1). This failure had the potential to result in a decline in activities of daily living and mobility when pain was not managed. Findings: A review of Resident 1 ' s admission Record, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure (a condition when the lungs cannot get enough oxygen into the blood), metabolic encephalopathy (a condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), and urinary tract infection [(UTI), an infection in any part of the urinary tract). Resident 1 ' s admission Record indicated Resident 1 was discharged from the facility on 4/22/2022. A review of Resident 1 ' s History and Physical (H&P), dated 1/29/2022, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1 ' s…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure timely notification to the physician was conducted for one of three sampled residents ' (Resident 1) abnormal urinalysis (analysis of urine by physical, chemical, and microscopical means to test for the presence of disease) results. This deficient practice resulted in the delay of the urinary tract infection ([UTI] when bacteria enter the urinary tract; kidneys, bladder, or urethra) treatment for Resident 1. Findings: A review of Resident 1 ' s admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure (a condition when the lungs could not get enough oxygen into the blood), metabolic encephalopathy (brain disorder) and UTI. The admission Record indicated Resident 1 was discharged from the facility on 4/22/2022. A review of Resident 1 ' s History and Physical (H&P), dated 1/29/2022, indicated Resident 1 did not have the capacity to understand and make decisions. 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 interview and record review, the facility failed to implement its abuse policy and procedure (P&P) titled, Abuse Reporting and Investigation, by failing to report misappropriation of funds to the State Licensing Agency (SA) within two hours, for one out of three sampled residents (Resident 2). This deficient practice resulted to the delay in investigation by the California Department of Public Health (CDPH). Findings: A review of Resident 2 ' s admission record indicated Resident 2 was admitted to the facility on [DATE], with diagnoses that included fracture of the left femur (a break in the left thigh bone), hypertension (high blood pressure) and history of falling. A review of Resident 2 ' s history and physical (H&P) dated 1/12/2024, the H&P indicated Resident 2 had the capacity to understand and make medical decisions. During a review of Resident 2 ' s minimum data set ([MDS] a standardized care assessment and care screening tool), dated 2/28/2024, the MDS indicated Resident 2 ' s cognitive skills…

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 thorough investigation was conducted for one of three residents (Resident 2), after alleged fraudulent (unauthorized) charges were reported to the facility by the Ombudsman ' s office (patient advocate). This deficient practice resulted to the misappropriation of Resident 2 ' s funds and placed Resident 2 and other residents at risk for further financial abuse. Findings: A review of Resident 2 ' s admission record indicated Resident 2 was admitted to the facility on [DATE], with diagnoses that included fracture of the left femur (a break in the left thigh bone), hypertension (high blood pressure) and history of falling. A review of Resident 2 ' s history and physical (H&P) dated 1/12/2024, the H&P indicated Resident 2 had the capacity to understand and make medical decisions. During a review of Resident 2 ' s minimum data set ([MDS] a standardized care assessment and care screening tool), dated 2/28/2024, the MDS indicated Resident 2 ' s…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to accurately document provision of Restorative Nursing Assistant (RNA) services for three of three sampled residents (Resident 1, Resident 5 and Resident 6). This deficient practice had the potential to negatively affect delivery of care/services to Residents 1, 5 and 6. Findings: A review of Resident 1 ' s admission Record, indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including respiratory failure (condition that makes it difficult to breath), hemiplegia (paralysis that affects one side of the body) and hemiparesis (muscle weakness one side of the body) following cerebral infarction (stroke). A review of Resident 1 ' s History and Physical (H&P) dated 12/6/2023, indicated Resident 1 had the capacity to decisions. A review of Resident 1 ' s Minimum Data Set ([MDS] a standardized care assessment and care screening tool), dated 3/12/2024, indicated Resident 1 was able to understand and be understood by others.…

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 implement its Policy and Procedure (P&P) titled, Abuse Reporting and Investigation dated 1/10/2024 which indicated, all allegations of abuse would be reported to the California Department of Public Health (CDPH) within 2 hours for two of five sampled residents (Resident 1 and Resident 4) after Resident 1 threw water towards Resident 4. This deficient practice had the potential for the underreporting of abuse incidents and a delay in the investigation by the CDPH. Findings: A review of Resident 1 ' s admission Record, indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including respiratory failure (condition that makes it difficult to breath), hemiplegia (paralysis that affects one side of the body) and hemiparesis (muscle weakness one side of the body) following cerebral infarction (stroke). A review of Resident 1 ' s History and Physical (H&P) dated 12/6/2023, indicated Resident 1 had the capacity to decisions. 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 observation, interview and record review, the facility failed to thoroughly investigate an allegation of abuse and separate two of five sampled residents (Resident 1 and Resident 4) after Resident 1 reported to Certified Nurse Assistant (CNA) 5, he threw water at Resident 4 on 3/14/2024. This deficient practice had the potential to result in unidentified abuse and ongoing abuse for Resident 4. Findings: A review of Resident 1 ' s admission Record, indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including respiratory failure (condition that makes it difficult to breath), hemiplegia (paralysis that affects one side of the body) and hemiparesis (muscle weakness one side of the body) following cerebral infarction (stroke). A review of Resident 1 ' s History and Physical (H&P) dated 12/6/2023, indicated Resident 1 had the capacity to decisions. A review of Resident 1 ' s Minimum Data Set ([MDS] a standardized care assessment and care screening tool), dated 3/12/2024, 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 skin treatment was provided and monitoring for bilateral (both) upper and lower extremities (arms and legs) swelling were conducted according to the physician ' s orders for one of four sampled residents (Resident 1). These failures had the potential to result in the worsening of Resident 1 ' s skin condition and could negatively affect the resident ' s health and well-being. Findings: During a record review of Resident 1 ' s admission Record (Face Sheet), the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including pneumonia (an infection that inflames the air sacs in one or both lungs), adult failure to thrive (a state of decline that may be caused by diseases and impairments causing weight loss, poor nutrition and inactivity), and heart failure (occurs when the heart muscle doesn't pump blood as well as it should). During a review of Resident 1 ' s physician ' s…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) received care and services to prevent the development of a pressure ulcer (damage to the skin and/or underlying skin tissue) according to the physician ' s orders, care plan and standards of practices. This deficient practice had the potential to result in the development of pressure ulcer for Resident 1. Findings: During a record review of Resident 1 ' s admission Record (Face Sheet), the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including pneumonia (an infection that inflames the air sacs in one or both lungs), adult failure to thrive (a state of decline that may be caused by diseases and impairments causing weight loss, poor nutrition and inactivity), and heart failure (occurs when the heart muscle doesn't pump blood as well as it should). During a review of Resident 1 ' s physician ' s orders dated 9/6/2023, 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 appropriate discharge was provided for a one of eight residents (Resident 8). Resident 8 was discharged home, pending the result of the second Medicare appeal (a notice of discharged from the hospital or that other types of services will be discontinued) results filed with the Livanta (reviewers that conduct medical record review by following Medicare medical review standards for various beneficiary appeals related to the cessation of services, such as hospital discharges, termination of skilled nursing services, and other beneficiary appeals.) This deficient practice had the potential to result in resident's needs not being met at discharge and placed the resident's safety in jeopardy. Findings: During a review of Resident 8 ' s admission record, the admission record indicated Resident 8 was admitted on [DATE], with a diagnosis that included displaced intertrochanteric fracture of right femur (break between the lesser trochanter and the area…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a care plan for three of five sampled residents (Resident 2, Resident 4, Resident 5), who were exposed to the corona virus ([COVID-19]- an infectious virus that spreads from person to person and affects how a person breathes] infection. This deficient practice had the potential to place Resident 2, Resident 4 and Resident 5 at risk for COVID-19 infection. Findings: During a review of Resident 2 ' s admission Record, the admission record indicated Resident 2 was admitted on [DATE] with a diagnosis that included colon cancer (cancer cells in the colon or rectum grow out of control), bladder mass (tumor in the bladder), muscle weakness (loss of muscle mass). During a review of Resident 2 ' s history and physical (H&P) dated 1/9/2024, the H&P indicated Resident 2 had the mental capacity to understand and make medical decisions. During a review of Resident 2 ' s physician orders dated 1/9/2024, the physician orders indicated Resident 2 had an order…

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 four of 14 sampled residents (Residents 54, 134, 66, and 31) medical records were initiated and/or updated to show documentation that Physician Orders for Life Sustaining Treatment (POLST- a form with written medical orders from a physician, nurse practitioner or physician assistant that helps give people with serious illnesses more control over their own care by specifying the types of medical treatment they want to receive during serious illness) and advance directives (a written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) were discussed and written information were provided to the residents and/or responsible parties. 1. Facility failed to have Resident 54 Advance Directive in the medical chart. 2. Facility failed to complete part C of the POLST for Resident 134. 3. Facility failed to have a completed POLST 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 observation and interview the facility failed to ensure the nightstand table drawer easily opened and closed for one out of five Residents (Resident 34). This deficient practice had the potential not to meet Resident 34's needs. Findings: During a review of Resident 34's admission Record (Face Sheet), the Face Sheet indicated Resident 34 admitted to the facility on [DATE]. Resident 34's diagnoses included epilepsy (a sudden, uncontrolled burst of electrical activity in the brain), osteoarthritis (degenerative joint disease in which the tissues in the joint breakdown over time), and neuropathy (when nerve damage leads to pain, weakness, numbness or tingling in one or more parts of the body). During a review of Resident 34's History and Physical (H&P), dated 4/5/2023, the H&P indicated Resident 34 has the capacity to understand a make decision. During a review of Resident 34's Minimum Data Set ([MDS] a comprehensive assessment and care-screening tool), dated 10/12/2023, the MDS indicated Resident 34's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one out of five residents (Resident 134) had a physician order for isolation precautions. This deficient practice of not having a physician order for isolation precautions placed the Resident 134 at risk for having the incorrect protection against infection for the staff and other residents. Findings: During a review of Resident 134's admission Record (Face Sheet), the Face Sheet indicated Resident 134 admitted to the facility on [DATE]. Resident 34's diagnoses included femur fracture (a break in the thighbone), hypertension (a condition in which the blood vessels have persistently raided pressure), and glaucoma (a chronic, progressive eye disease caused by damage to the optic nerve, which leads to visual field loss). During a review of Resident 134's History and Physical (H&P), dated 12/16/2023, the H&P indicated Resident 134 has the capacity to understand a make decision. During an observation on 12/26/2023 at 9:30a.m. a sign was noted on 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 implement a comprehensive care plans for one of two sampled residents (Resident 31). This failure had the potential for unmet care needs. Findings: During a review of Resident 31's admission Record, dated 12/23/2023, the admission record indicated Resident 31 was initially admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses which included pneumonia (an infection of the lungs), diabetes (blood sugar level is too high), dementia (a loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs). During a review of Resident 31's Minimum Data Set (MDS - a standardized resident assessment care screening tool), dated 12/5/2023, the MDS indicated Resident 31 was severely impaired with cognitive skills (ability to understand and make decision) for daily…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one out of five Residents (Resident 134) had a revised care plan. This deficient practice of not revising the care plan for Resident 134 had the potential to spread infection to other Residents and Staff. Findings: During a review of Resident 134's admission Record (Face Sheet), the Face Sheet indicated Resident 134 admitted to the facility on [DATE]. Resident 34's diagnoses included femur fracture (a break in the thighbone), hypertension (a condition in which the blood vessels have persistently raided pressure), and glaucoma (a chronic, progressive eye disease caused by damage to the optic nerve, which leads to visual field loss). During a review of Resident 134's History and Physical (H&P), dated 12/16/2023, the H&P indicated Resident 134 has the capacity to understand a make decision. During a review of Resident 134's Minimum Data Set ([MDS] a comprehensive assessment and care-screening tool), dated 12/19/2023, the MDS indicated Resident 134's…

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

Based interview and record review, the facility failed to effectively manage a resident's pain for one of one resident, Resident 70 as evidenced by. 1. The facility staff failed to call the physician after Resident 70 experienced excruciating pain unrelieved by the pain medication administered as ordered by the physician. As a result, after ineffective pain management, Resident 70 was laid in the bed all night in pain. Findings: A review of Resident 70 admission Record, dated 12/28/23, with a diagnosis that included abnormalities of gait and mobility (a change in walking pattern), muscle weakness (a lack of muscle strength), inflammatory response syndrome (Sepsis if the systemic response to infection), Respiratory failure (a condition in which your blood doesn't have enough oxygen or has too much carbon dioxide), Type 2 diabetes mellitus (happens because of a problem in the way the body regulates and uses sugar as a fuel)with hyperglycemia (high blood sugar level), Hemiplegia and Hemiparesis (paralysis that affects only one side of your body), Hyperlipidemia (abnormally 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 interviews and record review, the facility failed to ensure that a licensed pharmacist performed a monthly medication regimen review (MRR- a thorough evaluation of the medication regimen of a resident to promote positive outcomes and minimize adverse consequences and potential risks associated with medication) for one of three sampled residents (Resident 10) reviewed for unnecessary medications. This deficient practice placed Resident 10 at risk of receiving unnecessary medications that could lead to significant medication-related adverse consequences (a harmful effect could by a medication). Findings: During a review, Resident 10's admission Record, dated 1/2/2023, indicated an admission to the facility on 9/6/2023 with diagnoses that included Parkinsonism (a problem of the brain and spinal cord which causes a person to have trouble controlling their body's movements that gets worse over time), anxiety disorder (persistent, excessive, and unrealistic worry about everyday things), schizophrenia (a serious mental illness in which people interpret reality abnormally and…

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

Based on observation, interview, and record review, the facility failed to remove an unlabeled, expired bottle of Pedialyte (an oral rehydration solution) from the medication room located at Nursing Station 1. This deficient practice had the potential to cause harm to a resident. The unlabeled, expired Pedialyte had the potential to grow harmful bacteria which could cause food poisoning or other illness and could mistakenly be given to one of the residents. Findings: During a concurrent observation and interview on 12/28/2023 at 1:07 p.m. at the medication room in Nursing Station 1, Licensed Vocational Nurse (LVN) 4, found one unlabeled, expired bottle of Pedialyte. The Pedialyte expired on November 20, 2023. LVN 4 stated no one should store expired Pedialyte in the medication room. LVN 4 also stated because the Pedialyte was not labeled she did not know which resident it belonged to. LVN 4 stated she does not believe any of the residents at the facility had an order for Pedialyte and she did not know why it was in the medication room. LVN 4 stated she would discard the expired…

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 product information review, the facility failed to maintain safe food handling practices. The facility failed to ensure frozen food products were labeled. This had the potential to result in foodborne illnesses in the highly susceptible resident population. Findings: During an observation on 12/26/2023 at 8:30 a.m., there was one bag of hashbrowns dated 6/8/2023 use by 12/8/2023, undated opened muffins, cookies, cheese, pastry dough. and the top of the coffee maker was dusty. During an observation and interview on 12/27/2023 at 8:57 a.m. with DSS. The DSS stated when food is left open it can cause cross contamination and resident can get sick. DSS stated when food is not used by date a resident might become sick. A review of the facility policy & proceedure (P&P), titled Labeling and dating of foods (undated) indicated all food items in the storeroom, refrigerator, and freezer need to be labeled and dated. Newly opened food items will need to be closed and labeled with an open date and used by the date that follows the various storage guidelines…

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 and interview, the facility failed to implement infection control measures by failing to: 1. Ensure the facility's housekeeping aide performed hand hygiene after cleaning resident's rooms. 2. Perform appropriate hand hygiene while providing wound care treatment for one od one residents (Resident 15). 3. Change one of one sampled residents (Resident 66) oxygen tubing every seven days. These deficient practices had the potential to result in cross contamination of residents' environment, and the potential to spread microorganisms between the residents and the public. Findings: A. During an observation on 12/27/2023 at 9:34 a.m., in room [ROOM NUMBER], Housekeeping Aide 1 (HA 1) cleaned room [ROOM NUMBER]. HA 1 exited room [ROOM NUMBER] while wearing the same gloves. HA 1 touched the housekeeping cart and supplies removed the gloves and touched a personal protective equipment (PPE equipment worn to minimize exposure to hazards) storage cart outside of room [ROOM NUMBER]. HA 1 walked directly 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, interview and record review, the facility failed to follow their infection prevention and control policy and procedure (P&P) by failing to report the facility's Coronavirus Disease ([Covid-19] a highly contagious respiratory infection caused by a virus that could easily spread from person to person) outbreak (at least one confirmed Covid-19 resident case who had resided in the facility for at least 7 days) to the California Department of Public Health (CDPH) District Office. This deficient practice had the potential to result in a delay of the District Office' response to the the facility's Covid-19 outbreak and result in the spread of covid-19 infection to other residents, staff, and visitors. Findings: During an observation on 11/8/2023 at 9:20 a.m., 13 residents were observed in the red cohort/zone (area in the facility to house residents who was positive for Covid-19). During an interview on 11/8/2023 at 10:30 a.m., with the Assistant Director of Nursing (ADON), the ADON stated the Covid-19 outbreak started on 11/4/23 with one resident who had symptoms 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.