Las Flores Convalescent Hospital

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the removal of one of one sampled resident's (Resident 10) indwelling foley catheter (a hollow tube inserted into the bladder to drain or collect urine) was documented in the resident's progress notes. This deficient practice had the potential for miscommunication, not receiving continuity of care and the potential to not receive the appropriate care and services Resident 10 needs.Findings:During a review of Resident 10's admission Record, the admission Record indicated, Resident 10 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 10's diagnoses included chronic obstructive pulmonary disease ([COPD] - a chronic lung disease causing difficulty in breathing), dementia (a progressive state of decline in mental abilities), and generalized muscle weakness (a loss of strength throughout most of the body, causing fatigue, and difficulty performing daily tasks).During a review of Resident 10's History and Physical…

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 close supervision for two of seven sampled residents (Resident 1 and Resident 2) reviewed for elopement (the act of leaving a facility unsupervised and without prior authorization) risk, by failing to ensure: 1. One-to-one (1:1- a dedicated nurse assigned to continuously observe and attend to a single resident, providing close supervision and immediate interventions when needed) monitoring every shift as indicated in the care plan. 2. The functionality of the wander guard system (a technology solution designed to detect, track, and alert staff when at high risk for elopement resident attempt to exit a designated area).These deficient practices resulted in Residents 1 and 2 eloping from the facility on 7/19/2025, unsupervised for several hours, placing the residents at risk for serious harm, including injury, exposure to environmental hazards, and death. Findings: a. During a review of Resident 1's admission Record, the admission Record…

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 protect the resident's right to be free from physical abuse (deliberate, aggressive, or violent behavior with the intention to cause harm), for one of two sampled residents (Resident 3) when Resident 4 physically attacked Resident 3.This deficient practice resulted in Resident 3 sustaining welts (raised, red, or skin-colored bumps that appear on the skin) to his left arm, after Resident 4 hit him with a clothes hanger.Findings: During a review of Resident 3's admission Record (face sheet), the face sheet indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted [DATE] with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought), anxiety (a feeling of worry or fear, often about potential future problems), and dementia (a progressive state of decline in mental abilities) with other behavioral disturbance. During a review of Resident 3's Care Plan titled, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the licensed nursing staff failed to develop a baseline care plan addressing identified mood/behavior concerns for one of five sampled residents (Resident 2).This deficient practice had the potential for delayed provision of necessary care and services.Findings:During a review of Resident 1's admission Record (face sheet), the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including anxiety (a feeling of worry or fear, often about potential future problems), psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), and depression (a mood disorder characterized by persistent feelings of sadness, loss of interest in activities, and a range of other symptoms that can significantly impair daily functioning.)During a review of Resident 1's History and Physical (H&P) dated 4/1/2025, the H&P indicated Resident 1 did not have capacity to understand and make…

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 Certified Nursing Assistant (CNA) 1 received staff training after a resident (Resident 5) accused CNA 1 of abuse during personal hygiene care.This deficient practice had the potential for CNA 1 to cause harm to residents if not properly trained regarding abuse.Findings:During a review of Resident 5's admission Record (face sheet), the admission record indicated Resident 5 was originally admitted to the facility on [DATE] and readmitted [DATE] with diagnoses including muscle weakness, schizophrenia (a mental illness that is characterized by disturbances in thought), anxiety (a feeling of worry or fear, often about potential future problems), dementia (a progressive state of decline in mental abilities) with psychotic disturbance (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality.) During a review of Resident 5's History and Physical (H&P), dated 3/11/2025, the H&P indicated Resident 5 had…

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

Based on observation, interview, and record review the facility failed to: 1. Follow its policy and procedure (P&P) to replace the portable container non-antibiotic medication Emergency-Kit (E-Kit) within 48-72 hours. 2. Implement its P&P titled, Disposal of Medication and Medication-Related Supplies, which indicated to ensure accurate destruction of all medications including narcotic (drug which relieves pain and induces drowsiness, stupor, or unconsciousness) were conducted with the signature of licensed nurse. These deficient practices placed all residents at risk for not providing medication during emergency situations and had the potential of loss or diversion of controlled medication. Findings: 1. During a concurrent observation and interview on 3/6/2025 at 2:16 p.m., in station 1 medication storage room with Licensed Vocational Nurse (LVN) 4, one E-Kit with prescription #836, with a red zip tie and one E-Kit with prescription #890 with a red zip tie was observed. LVN 4 stated a red zip tie meant the E-Kit had been opened. During a concurrent interview and record review 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 meet the professional standards of nursing practice by failing to: 1. Properly obtain accurate orthostatic blood pressure (a form of low blood pressure that happens when standing after sitting or lying down) readings for two of two sampled residents (Residents 1 and 25). This deficient practice had the potential for Residents 1 and 25 to experience a delay in interventions if they were positive for orthostatic hypotension (low blood pressure). 2. Ensure medication, Diclofenac Sodium External Gel 1% (a medication to treat pain and inflammation), was administered to the correct site as ordered by the physician for one of five sampled residents (Resident 96). This deficient practice had the potential to result in unintended complications of the medication, which could potentially lead to overdose or an adverse reaction for Resident 96. 3. Administer Midodrine HCI (a medication to treat low blood pressure) following parameters set by physician order for…

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

Based on interview, and record review, the facility failed to: 1. Complete initial and annual skills competencies for four of four Restorative Nursing Aide (RNA, nursing aide program that help residents to maintain their function and joint mobility) staff. This deficient practice had the potential to cause injury and worsening contractures (loss of motion of a joint) for 51 current residents who required RNA treatments. 2. Ensure their Licensed Vocational Nurse knew what the purpose of checking orthostatic hypotension (a condition where blood pressure drops significantly when a person stands up from a sitting or lying position or sits up from a lying position) was for and how to obtain blood pressure readings to check for orthostatic hypotension. This deficient practice had the potential to place residents at risk for a delay in care and services which could result in falls or injury. Findings: 1. During a concurrent interview and record review with the Director of Staff Development (DSD), on 3/6/2025 at 9:58 a.m., Restorative Nursing Aide 1 (RNA 1), Restorative Nursing Aide 2 (RNA…

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

Based on observation, interview, and record review the facility failed to store medications properly by failing to: 1. Ensure an unopened Lantus (a long lasting insulin [a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication]) pen, an unopened insulin vial and insulin pen of Glargine YFGN (a long lasting insulin [a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication]) were stored inside the refrigerator per manufacturer's guidelines. 2. Ensure a multi-dose medication container was clean and free from particles stored in medication cart 1. These deficient practices had the potential for the loss of efficacy of Lantus and Insulin Glargine YFGN, cause ineffective management of the residents' diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and had the potential for the resident to receive contaminated medications. Findings: 1. During a concurrent observation and interview on 3/6/2025 at 1:45 p.m., 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 have laboratory orders implemented for three of six sampled residents (Residents 25, 42 and Resident 100) by failing to: 1.Ensure Resident 25 and Resident 42 had laboratory orders drawn as ordered by the physician. 2. Ensure Resident 100 had a Keppra (anti-seizure drug) level blood draw (a procedure in which a needle is used to take blood from a vein, usually for laboratory testing) monthly. These deficient practices caused Resident 25 and Resident 42 a delay in care and placed Resident 100 at risk for seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) Findings: 1. During a review of Resident 25's admission Record (document containing basic information regarding a resident), The admission Record indicated Resident 25 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included acute kidney failure (a sudden decline in kidney function),…

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

Based on observation, interview, and record review, the facility failed to ensure the dietary staff followed proper storage practices in the kitchen by: 1. Not properly closing opened bags of dry food and ensuring the dry food products were stored in containers with tight fitting lids. 2. Not dating opened multi-use containers. This deficient practice had the potential to result in the attraction of pests and contamination of food served to residents. Findings: During an observation on 3/4/2025 at 8:20 a.m. in the kitchen dry storage room, three bags of dry cereal were observed with plastic wrap tied loosely around the bag, causing the bag to stay open. An opened gallon of pancake mix and waffle syrup without a label indicating the date it was opened was also observed. During a concurrent observation and interview on 3/4/2025 at 8:25 am in the kitchen dry storage room with Dietary Aide (DA), the DA stated the dry cereal bags were not tied close and could allow pests to enter the bag and contaminate the food. The DA stated the bottle of pancake mix and waffle syrup were not labeled…

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 contingency plan (a pre-defined set of actions to be taken if an original plan fails or an unexpected event occurs) was developed and included in the Facility Assessment (a process for evaluating a facility's resident population and identifying the resources needed to provide care and services). This deficient practice had the potential for the facility to ineffectively respond during unexpected circumstances and negatively impact resident care. Findings: During a concurrent interview and record review on 3/5/2025 at 9:25 a.m., with the Administrator (ADM), the Facility's assessment dated [DATE], was reviewed. The ADM stated the Facility's Assessment was incomplete. The ADM stated the Facility's Assessment did not include the contingency plan including staffing needs during emergency that would affect resident's care. The ADM stated the Facility Assessment was an overview of the resident population and it reflected the services provided by 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 interview and record review, the facility failed to provide meeting minutes (notes) of the Quality Assurance and Performance Improvement ([QAPI] - a data driven proactive approach to improvement used to ensure services are meeting quality standards) program to prove three repeat deficiencies in the areas of Resident Rights, Laboratory Services, and Pharmacy Services, cited during the previous recertification survey of 2024, were discussed and evaluated. This deficient practice had the potential for repeated deficiencies and placed the residents at risk for harm if areas identified were not investigated, analyzed and ensure corrective actions or activities to improve performance were effectively implemented. Findings: During a review of documents titled, Statement of Deficiencies (SOD), dated 3/8/2024, the SOD indicated the facility had deficiencies related to Resident Rights, Laboratory Services, and Pharmacy Services. During an interview on 3/7/2025 at 11:47 a.m., with the Administrator (ADM), the ADM stated the facility did not have any minutes or any evidence of QAPI…

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 and interview, the facility failed to ensure five wheelchairs (WC, chair fitted with wheels for transport) and one geriatric chair (a large, padded chair designed to help persons with limited mobility) were not stored outside, under the rain. This deficient practice had the potential to cause damage to medical equipment and prevent safe use of WCs and geriatric chairs for residents residing the facility. Findings: During an interview on 3/5/2025 at 8:53 a.m. with the Director of Rehabilitation (DOR), the DOR stated the facility had difficulty maintaining and keeping WCs, because the WCs get lost. During an observation and interview on 3/5/2025 at 1:16 p.m. in the therapy gym, the DOR stated he prepared and cleaned a WC for a resident, but it was stored outside in the rain, and now needed to be dried. The DOR stated because the WC was outside and was wet, the WC could not be used for the resident today and hopefully, would be dried by tomorrow for resident use. The DOR stated there was no other WC for the resident to use because the resident required a custom WC.…

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. Ensure a resident and/or responsible party (RP) was informed in advance, of the risks and benefits of psychoactive medication (a drug that changes brain function and results in altercations in perception, mood, consciousness, or behavior) for one of five residents (Resident 46). This deficient practice violated the residents' right to make an informed decision regarding the use of psychoactive medications. Findings: During a review of Resident 46's admission Record, the admission Record indicated, Resident 46 was initially admitted to the facility on [DATE] and latest readmission was on 2/7/2025. Resident 46's diagnoses included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic kidney disease (CKD-condition which the kidneys are damaged and cannot filter blood as well as they should), and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from 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: 1. Ensure one of 25 sampled residents (Resident 275) participated in care planning meetings. This deficient practice violated Resident 275's rights to be fully informed of the resident's plan of care and had the potential to result in delay of care and services. Findings: During a review of Resident 275's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 275 was admitted to the facility on [DATE]. Resident 275's diagnoses included chronic obstructive pulmonary disease ([COPD] - a chronic lung disease causing difficulty in breathing), hypertension ([HTN] - high blood pressure), and congestive heart failure ([CHF] - a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a review of Resident 275's History and Physical (H&P), dated 1/7/2025, the H&P indicated, Resident 275 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one out of six sampled resident's (Resident 36 and Resident 224) call light was within reach. This deficient practice had the potential to result in a delay in or an inability for the residents to obtain necessary care and services. Findings: A. During a review of Resident 36'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 36 was admitted to the facility on [DATE]. Resident 36's diagnoses included chronic obstructive pulmonary disease ([COPD]- a chronic lung disease causing difficulty in breathing), hemiplegia (paralysis of the arm, leg, and trunk on the same side of the body), and muscle weakness (a lack of muscle strength). During a review of Resident 36's History and Physical (H&P), date unknown, the H&P indicated, Resident 36 had the capacity to understand and make decisions. During a review of Resident 36's Minimum Data…

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 25 sampled resident's (Resident 273) preference to have a shower was honored. This deficient practice had the potential to affect Resident 273's psychosocial wellbeing. Findings: During a review of Resident 273's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 273 was admitted to the facility on [DATE]. Resident 273's diagnoses included urinary retention (a condition that makes it difficult to empty your bladder), dysphagia (difficulty of swallowing), and urinary tract infection ([UTI] - an infection in the bladder/urinary tract). During a review of Resident 273's History and Physical (H&P), dated 3/2/2025, the H&P indicated, Resident 273 had the capacity to understand and make decisions. During a review of Resident 273's Minimum Data Set ([MDS] - a resident assessment tool), dated 3/4/2025, the MDS indicated Resident 273 was independent…

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 inform and provide the Notice of Medicare Non-Coverage ([NOMNC] - a notice that indicates when your care is set to end from a skilled nursing facility) form 48 hours prior to the end of skilled nursing services to resident representative for one of three sampled residents (Resident 32). This deficient practice had the potential to result in the resident not being able to exercise his right to file an appeal and unknowingly paying for non-covered care expenses. Findings: During a review of Resident 32's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated Resident 32 was admitted to the facility on [DATE]. Resident 32's diagnoses included unspecified dementia (a progressive state of decline in mental abilities), cerebrovascular accident ([CVA] - a stroke, loss of blood flow to a part of the brain), and dysphagia (difficulty of swallowing). 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to transmit the Minimum Data Set ([MDS] - a resident assessment tool) within 14 days after completion to the Centers for Medicare and Medicaid Services (CMS) for one of 25 sampled residents (Resident 93). This deficient practice resulted in incorrect data transmitted to CMS and had the potential to affect continuity of care. Findings: During a review of Resident 93's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated Resident 93 was admitted to the facility on [DATE]. Resident 93's diagnoses included diabetes mellitus ([DM] - a disorder characterized by difficulty in blood sugar control and poor wound healing), cerebrovascular accident ([CVA] - a stroke, loss of blood flow to a part of the brain), and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 93's Minimum Data Set ([MDS] - a resident assessment tool),…

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 care plan for Seroquel (antipsychotic, class of medications that treat mental illness) or Duloxetine (antidepressant, used to treat depression [feeling of sadness and low mood] was formulated for one of 25 sampled residents (Residents 46). This deficient practice had the potential for the affected resident not to receive the care and services needed and the provision of a poor-quality care. Findings: During a review of Resident 46's admission Record, the admission Record indicated Resident 46 was initially admitted to the facility on [DATE] and latest readmission was on 2/7/2025. Resident 46's diagnoses included diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic kidney disease (CKD-condition which the kidneys are damaged and cannot filter blood as well as they should), and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows 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 provide one of six sampled residents (Resident 104) with care and services to perform activities of daily living (ADLs, basic daily activities such as eating and transferring) by failing to provide Resident 104 with an appropriate wheelchair (WC, chair fitted with wheels for transport) for transfers and out of bed activities. This deficient practice had the potential for Resident 104 to experience a decline in overall physical and mental wellbeing. Findings: During a review of Resident 104's admission Record, the admission record indicated Resident 104 was readmitted to the facility on [DATE] with diagnoses including muscle weakness and lack of coordination. During a review of Resident 104's Initial History and Physical (H&P) dated 12/3/2024, the H&P indicated Resident 104 had the capacity to understand and make decisions. During a review of Resident 104's Minimum Data Set (MDS, resident assessment tool) dated 12/9/2024, the MDS 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, interview, and record review, the facility failed to provide one of three sampled residents (Resident 24), with activities outside of the resident's room. This failure caused the resident to feel isolated and lacking socializing with residents outside her room. Findings: During a review of Resident 24's admission Record, the admission record indicated the facility admitted Resident 24 on 5/18/2016 and re-admitted on [DATE], with diagnoses that included hemiplegia and hemiparesis affecting left side (conditions that causes paralysis and weakness) and epilepsy (a chronic brain disorder that causes recurrent seizures). During a review of Resident 24's Minimum Data Set (MDS - a resident assessment tool) dated 2/10/2025, the MDS indicated Resident 24 had the ability to express ideas and wants and the ability to understand others. The MDS also indicated it was very important for Resident 24 to do things with groups of people and go outside to get fresh air when the weather is good. 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 provide appropriate services to prevent a decline in joint range of motion (ROM, full movement potential of a joint) for two out of 10 sampled residents (Resident 3 and 27) who had limited ROM by failing to: 1. Ensure Resident 3 received timely quarterly (every three months) Rehabilitation Joint Mobility Assessments (JMA) to monitor changes in joint range of motion. 2. Ensure Resident 27 had a left elbow splint was placed five days a week. These deficient practices had the potential to cause further decline in Resident 3 and Resident 27's ROM and overall quality of life. Findings: A. During a review of Resident 3's admission Record, the admission record indicated Resident 3 was re-admitted to the facility on [DATE] with diagnoses including but not limited to hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) cerebrovascular disease (disease of the blood vessels, especially blood vessels…

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 one out of six sampled residents (Resident 57) head of bed ([HOB] -raising the head of the bed to help patients reduce the risk of aspiration in patients receiving enteral nutrition) was in proper position while the enteral tube feed ([TF]- a delivery of nutrition bypassing the mouth directed to the stomach when a patient cannot safely eat nutrition directly ) was running. This deficient practice of not having the HOB in proper position placed Resident 57 at risk for aspiration (inhalation of food, liquids, other material into the lungs). Findings: During a review of Resident 57'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 57 was initially admitted to the facility on [DATE] and was last readmitted on [DATE]. Resident 57's diagnoses included gastro-esophageal reflux disease ([GERD]- a condition which 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 interview and record review, the facility failed to: 1. Assess the insertion site of a Peripherally Inserted Central Catheter ([PICC Line] - a flexible tube that is inserted into a vein in the upper arm and guided into a large vein above the right side of the heart) at least once every shift and change the dressing every 7 days for one of one sampled resident (Resident 21). This deficient practice had the potential for Resident 21's PICC line insertion site to develop infection and other complications. Findings: During a review of Resident 21's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 21 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 275's diagnoses included sepsis (a life-threatening infection), diabetes mellitus ([DM] - a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertension ([HTN] - high blood sugar). 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: 1. Ensure pain was managed for one of 25 sampled residents (Resident 224) in a timely manner. This deficient practice resulted in Resident 224 experiencing unnecessary pain. Findings: During a review of Resident 224's admission Record, the admission Record indicated, Resident 224 was admitted to the facility on [DATE]. Resident 224's diagnoses included difficulty walking, muscle weakness, asthma (a chronic lung disease making it difficult to breathe), and congestive heart failure (CHF- heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a review of Resident 224's History and Physical (H&P), dated 2/16/2025, the H&P indicated Resident 224 had the capacity to understand and make decisions. A review of Resident 224's Minimum Data Set (MDS - a resident assessment tool), dated 2/21/2025, indicated Resident 224 was assessed to comprehend (the action or capability of understanding something)…

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 six sampled residents (Resident 100) orders for prescribed eye drops were carried out. This deficient practice of not following the physician orders for prescribed eye drops had the potential for worsening of Resident 100's eye conditions. Findings: During a review of Resident 100'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 100 was admitted to the facility on [DATE]. Resident 100's diagnoses included respiratory failure (a condition in which you blood does not have enough oxygen or has too much carbon dioxide), epilepsy (a condition characterized by recurrent, unprovoked seizures, caused by abnormal electrical activity in the brain), and polycystic kidney (a genetic disorder characterized by the growth of numerous fluid-filled cysts in the kidneys). During a review of Resident 100's History and Physical (H&P), the 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 ensure safe and sanitary storage practices of foods brought to residents by family and other visitors were followed for one of three sampled residents (Resident 42) when: 1. Resident 42's personal food item was not stored per manufacturer's directions. 2. Resident 42's personal food item was not labeled according to the facility's policy and procedure (P&P) titled, Food Brought in by Visitors which indicated perishable food will be labeled, dated, and discarded after 48 hours. This deficient practice had the potential for Resident 42 to experience foodborne illness (food poisoning). Findings: During a review of Resident 42's admission Record, the admission Record indicated Resident 42 was initially admitted on [DATE] and readmitted on [DATE]. Resident 42's diagnoses included Vitamin D deficiency, hyperlipidemia (high level of fats in the blood), and gastro-esophageal reflux disease (GERD- stomach contents flow back up into the esophagus,…

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 in resident clinical records, when one of 25 sampled residents (Resident 76), was sent to General Acute Care Hospital (GACH) from dialysis center (a health office/clinic for treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidneys have failed) due to unresponsiveness (a state where resident was not responding to stimuli). This deficient practice had the potential to cause delay in communication among staff and placed Resident 76 at risk of not receiving appropriate care. Findings: During a review of Resident 76's admission Record, the admission Record indicated, Resident 76 was admitted to the facility on [DATE]. Resident 76's diagnoses included End Stage Renal Disease ([ESRD] - irreversible kidney failure), anemia (a condition where the body does not have enough healthy red blood cells), and dysphagia (difficulty of swallowing). During a review of Resident 76's Minimum Data Set ([MDS] - 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 allow one of three sampled residents, (Resident 2), to exercise the right to refuse treatment, as indicated in the facility's operational manual, titled Resident Rights: Refusal of Treatment. This failure had the potential to cause Resident 2 to experience psychosocial harm. Findings: During a review of Resident 2 ' s admission Record indicated Resident 2 was admitted to the facility on [DATE] with a diagnosis of Type 2 Diabetes Mellitus ([DM], a disorder characterized by difficulty in blood sugar control and poor wound healing) without complications, hypertension (HTN-high blood pressure) and hoarding disorder. During a review of Resident 2 ' s History and Physical (H&P), dated 10/07/2024, the H&P indicated Resident 2 had the capacity (the ability to hold) to understand and make decisions. During a review of Resident 2 ' s Minimum Data Set (Minimum Data Set [MDS] a federally mandated resident assessment tool), the MDS dated [DATE], indicated 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 interview and record review, the facility failed to ensure four of four sampled residents (Residents 1, 7, 8, and 9) was treated with respect and dignity when Certified Nurse Assistant (CNA 4): 1. Acted rudely and spoke to Resident 1 in a demanding voice during care. 2. Refused to stay with Resident 7 when the resident asked the CNA to wait for her while having a bowel movement. 3. Spoke loudly towards Resident 8. 4. Spoke in a harsh tone towards Resident 9 and repositioned the resident in a fast and hurried way. This deficient practice violated the resident's rights to be treated with respect and dignity and had the potential to negatively affect the self-esteem and psychosocial well-being of the residents. Findings: During a Review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 1 ' s diagnoses included diabetes mellitus ([DM] a disorder characterized by difficulty in blood sugar control and poor…

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 and interview, the facility failed to ensure Dietary staff followed proper sanitation practices in the kitchen by not sweeping and mopping the kitchen floors as indicated on the Cleaning Schedule. This deficient practice had the potential to result in attracting pests in the kitchen and contamination of food served to the residents. Findings: During an observation on 10/22/2024 at 11:30 a.m., in the kitchen, food residue, dirt, and other debris on the floors behind black cabinets, behind and on the side of the dish washing machine, under the sink, under the refrigerator, and under and on the side of the stove were observed. During an interview on 10/23/2024 at 11:19 a.m., with the Dietary Aid (DA), the DA stated the daily assigned dishwasher would sweep after washing the dishes. The DA stated if the kitchen floor was not cleaned well, resident ' s food could become contaminated and could attract bugs. During a concurrent record review and interview on 10/23/2024 at 11:33 a.m., with the Dietary Supervisor (DS), surveyor pictures of the kitchen were reviewed. 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 the abuse prevention program policy and procedure by not reporting an allegation of abuse for one of four sampled residents (Resident 1) to the California Department of Public Health ([CDPH]- state agency), after Family Member (FM) 1 stated Certified Nurse Assistant (CNA) 1 raised her arm to hit Resident 1. This deficient practice had the potential for under-reporting abuse incidents, delay in investigation of an abuse allegation, and placed Resident 1 and other residents at risk for further abuse. 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 hemiplegia (paralysis on one side of the body), and hemiparesis (weakness or inability to move one side of the body) following intracranial hemorrhage (brain bleed), and syncope (fainting or passing out). During 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 submit the results of the investigation of an injuries of unknown source to the state agency (California Department of Public Health [CDPH]) within 5 working days of the incident for one of three sampled residents (Resident 1). This deficient practice delayed the CDPH investigation of unknown source of injury of Resident 1. Findings: A review of Resident 1's admission Record, the admission Record indicated, Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included dementia (loss of cognitive functioning, thinking, remembering, and reasoning), cerebral infarction (loss of blood flow to part of the brain) with hemiparesis (weakness or inability to move on one side of the body), and contractures (limitation in range of motion) on left elbow, left ankle, and right ankle. A review of Resident 1's History and Physical (H&P), dated 3/1/2024, indicated, Resident 1 did not have 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.

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 Prevention and Prohibition Program: Operational Manual-Abuse & Neglect, which indicated the facility should report allegations of abuse immediately, but no later than two hours. This failure delayed the investigation by the California Department of Public Health (CDPH). Findings: 1). A review of Resident 1 ' s admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke), schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves) and extrapyramidal movements (involuntary, uncontrollable movements). A review of Resident 1 ' s Minimum Data Set (Minimum Data Sheet [MDS] a standardized assessment and care screening tool), dated 4/15/2024, indicated Resident 1 had severe cognitive impairment (the ability to think and reason). The MDS indicated Resident 1 was independent with mobility. 2).…

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 and implement a physician telephone order to flush urinary catheter (a tube placed in the body to drain and collect urine from the bladder), monitor characteristics of urine and document urine output for 1 of 4 sampled residents (Resident 1). These failures resulted in Resident 1 being admitted to the general acute care hospital (GACH) with bladder distention (when the pouch that holds your urine is enlarged) and infection. Findings: A review of Resident 1 ' s admission record, dated 5/15/24, the admission record indicated Resident 1 was initially admitted on [DATE] and re-admitted [DATE], with diagnosis of benign prostate hyperplasia ([BPH]a condition in men in which the prostate gland is enlarged and not cancerous) with lower urinary tract symptom ' s, adult failure to thrive, and cardiomegaly (enlargement of the heart). A review of Resident 1 ' s Minimum Data Set (MDS-an assessment and care planning tool) dated 5/16/24, the MDS 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 Resident 1 received cast/splint care for 5 months after being transferred to the SNF in accordance with professional standards of practice for one of one sampled resident (Resident 1). Resident 1 did not receive cast/splint care for 5 months after being transferred to SNF. Which resulted in Resident 1 not receiving proper cast care. These deficient practices resulted in the failure in the delivery of necessary care and services in receiving cast care, failing to implement its policy and procedures (P&P) related to cast care and accurately documenting in the initial admission assessment records. Findings: A review of Resident 1's admission records indicated Resident 1 was a 56- year-old male, admitted to the facility on [DATE]. Resident 1's diagnoses included non-displaced fracture of lateral malleolus of right fibula (ankle fracture), peripheral vascular disease (a condition in which narrowed blood vessels reduce blood flow to the limbs), venous…

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 all smoking residents are supervised while they smoke. 2. Cigarette butts are disposed of properly. This deficient practice had the potential to cause injury to residents. Findings: During an observation on 3/8/2024, at 9:03 AM, in the courtyard across from room [ROOM NUMBER], multiple cigarette butts were seen lying throughout the courtyard. There were no smoking bibs, fire extinguisher, ash trays and cigarette disposal bins in the courtyard. During an interview with the Activities Director (AD 1), on 3/8/2024 at 9:45 AM, AD 1 stated smoking is done at the designated smoking patio, and residents who are smoking are to be supervised by a staff member during the day and night. The times for smoking are posted throughout the facility and in the rooms of residents who do smoke. The smoking patio has smoking apron for residents to use, fire extinguisher, cigarette disposal bin and ash trays, and drinking water for residents. During…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: A. Ensure oxygen (air) tubing were dated, labeled, and changed every seven days per policy and procedure (P&P) for three of five sampled residents (Residents 77, 102, and 276). B. Ensure Resident 110 received three liters of oxygen as per physician's order. This deficient practice had the potential for four out of five sampled resident's (Residents 77, 102 and 276), to cause respiratory infection for residents on oxygen therapy and Resident 110's receiving less oxygen than required and can negatively impact the residents health and well-being. Findings: A. During an observation on 3/6/24 at 10:45 a.m., Resident 77 was wearing a nasal cannula (plastic tube used to give oxygen) and the tubing was not dated. During an interview on 3/7/24 at 8:47 a.m. with RN1, RN1 stated oxygen tubing should be used for a max of seven days. The tubing must be dated for infection control. During an interview on 3/8/24 at 11:30 a.m. with LVN4, LVN4 stated…

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 safe and sanitary food storage and food preparation practices in the kitchen when: 1. Unlabeled/undated food was found in the refrigerator and freezer. 2. Personal belongings were found stored with kitchen and resident supplies This deficient practice had the potential to result in the residents obtaining a food borne illness. Findings: 1. During an observation on 3/5/24 at 8:30 a.m., undated frozen ground beef was found in the freezer. Unlabeled and undated yogurt, salsa, and drinks were in the refrigerator. During an interview on 3/6/24 at 9:02 a.m. with CK3, CK3 stated when you stock and prepare food you have to put a date so you know how many days it has been there. If you don't know the date and give it to a resident, the resident can get sick. During an interview on 3/6/24 at 1:45 p.m. with DS1, DS1 stated all prepared foods in the refrigerator should have a date because you can only keep it for so many days. If the resident eats something that doesn't have a date they can get sick. Frozen foods…

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 and interview the facility failed to: 1. Ensure one out of three dumpsters were covered. This deficient practice had the potential to result in attracting rodents to the garbage site. Findings: During an observation on 3/7/24 at 8:55 a.m. one of the dumpsters was found propped open with a stick. During an interview on 3/7/24 at 9:02 a.m. with DS1, DS1 stated the dumpsters should be closed at all times. Leaving the dumpster open can attract rodents, pests and maggots. During an interview on 3/7/24 at 9:06 a.m. with Maintenance1, Maintenance1 stated the dumpsters should be closed. Leaving the dumpster open brings flies that can carry germs.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: A. Ensure a resident, who was totally dependent on staff for activities of daily living (ADL) a basic skill needed to carry out tasks of everyday life) and was not able to use a regular call light, was provided with a specialized call light in the form of a pad for one Resident 275. B. Ensure the call light was within reach for Resident 29 and Resident 120. This deficient practice had the potential for three out of five sampled resident's (Resident 275, 29 and 120), not being able to summon a staff member for help as needed and at risk for delay in obtaining necessary care and services. Findings: A. During a review of Resident 275's admission Record, the admission Record indicated, Resident 275 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) with hemiplegia (one-sided muscle paralysis or weakness) and hemiparesis (weakness or 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 Resident 44 had her blood pressure checked every six hours as ordered. This deficient practice had the potential to result in Resident 44 having a dangerously high blood pressure. Findings: During an interview on 3/8/24 at 11:30 a.m. with LVN4, LVN4 stated it is important to check the blood pressure as the doctor ordered because the blood pressure can go higher or lower than the normal range, and the resident can get dizzy and fall. During an interview on 3/8/24 at 11:50 a.m. with RN2, RN2 stated if the blood pressure is ordered to be checked every six hours it should be checked at 12:00 a.m., 6:00 a.m., 12:00 p.m., and 6:00 p.m. You have to monitor the blood pressure every six hours as the doctor ordered it because the blood pressure might go too high, and the resident can have a stroke. During a review of Resident 44's admission Record (Face Sheet), the Face Sheet indicated Resident 44 was admitted to the facility on [DATE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to: 1. Ensure Resident 24 received assistance with feeding as ordered by the physician. This deficient practice resulted in Resident 24 eating with her hand and had the potential to result in weight loss due to Resident 24's inability to eat properly. Findings: During an observation on 3/8/24 at 1:00 p.m., Resident 24 was eating unsupervised. Resident 24 was eating fish with a spoon using the right hand. Resident 24 was unable to eat the fish so she began eating it with her hand. Resident 24 was unable to reach her juice. Resident 24 was unable to see the mashed potatoes behind the coffee cup. Resident 24 is unable to use her left arm. During an interview on 3/8/24 1:05 p.m. with CNA5, CNA5 stated Resident 24 cannot use her left arm. CNA5 stated if no one is there to assist the resident it's a problem because the resident could have an issue getting something. During an interview on 3/8/24 at 1:09 p.m. with RN2, RN2 stated when a resident has…

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 have a medical doctors order for one of five sampled Residents (Resident 175). This deficient practice of not having a medical doctors order to cover Resident 175 right hand with a sock had the potential to cause Resident 175 psychosocial harm. Findings: During a review of Residents 175's admission Record (Face Sheet), dated 2/25/2024, the admission Record indicated Resident 175 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 175 diagnoses not limited to encephalopathy (damage or disease that affects the brain), type 2 diabetes mellitus (a disease that occurs when your blood sugar is too high), and respiratory failure (a lung issue that happens when there is insufficient oxygen passing through the lungs and into the blood). During a review of Residents 175's History and Physical (H&P), dated 3/1/2024, the H&P indicated, Resident 175 does not have the capacity to understand and make medical decisions.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident was provided with emotional support while grieving for one of one sampled resident (Resident 18). This deficient practice placed Resident 18 at risk for further depression and ineffective coping ability. Findings: During a review of Resident 18's admission Record, the admission Record indicated, Resident 18 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including end stage renal disease (a medical condition in which a person's kidney cease functioning on a permanent basis leading to the need for regular course of long-term dialysis or a kidney transplant to maintain life), anemia (blood disorder), and peripheral vascular disease (reduced circulation of blood to a body part). During a review of Resident 18's History and Physical (H&P), dated 10/18/2022, the H&P indicated, Resident 18 had fluctuating capacity to understand and make decisions. During a review of Resident 18's Minimum Data…

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 act on one recommendation from the pharmacy consultant (a professional responsible for reviewing each resident's medication profile monthly to identify and report changes) from December 2023, in one of five sampled residents (Resident 32). This deficient practice of failing to respond to recommendation from consultant pharmacist had the potential to result in Resident 32 receiving unnecessary medication. Findings: During a review of Resident 32's admission Record, the admission Record indicated, Resident 32 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including emphysema (a type of lung disease that causes breathlessness), diabetes mellitus type 2 (a chronic condition that happens when you have persistently high blood sugar levels), and peripheral vascular disorder (reduced circulation of blood to a body part). During a review of Resident 32's History and Physical (H&P), dated 9/17/2022, the 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.

Based on observation, interview, and record review, the facility failed to: 1. Remove one unopened vial of expired insulin a (medication that lowers blood sugar) from the facility's medication refrigerator room station one. 2. Remove one unopened vial of expired lorazepam (a medication indicated for treatment of anxiety) from the facility's emergency kit medication refrigerator room station two and station four. 3. Ensure routine room temperature monitoring and documentation were in place to ensure medications were within the temperature ranges as specified by the drug manufacturers, in three of three medication storage rooms. This deficient practice had the potential for harm to the residents due to potential loss of strength and ineffective medication dosages and had the potential for expired medications administered to the residents and can cause severe drug adverse reactions including hospitalizations. Findings: During a concurrent observation and interview on 3/8/2024 at 9:05 a.m. of the medication storage one with Licensed Vocational Nurse 5 (LVN 5), one expired unopened vial…

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 laboratory test ordered by the physician was completed and results available in the resident's clinical records for one of thirty-one sampled residents (Resident 275). This deficient practice had the potential to result in Resident 275 experiencing preventable complications from abnormal lab values, possibly leading to medical complications requiring hospitalization. Findings: During a review of Resident 275's admission Record, the admission Record indicated, Resident 275 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) with hemiplegia (one-sided muscle paralysis or weakness) and hemiparesis (weakness or the inability to move on one side of the body), local infection of the skin and subcutaneous tissue (deepest layer of the skin), and left hand contracture (decrease in range of motion). During a review of Resident 275's History and Physical…

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 the dialysis (a treatment that removes wastes and extra fluid from your blood) access type for one of two sampled residents (Resident 18). This deficient practice had the potential for Resident 18 to receive misinformation and not receiving the appropriate care and services and poor continuity of care. Findings: During a review of Resident 18's admission Record, the admission Record indicated, Resident 18 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including end stage renal disease (a medical condition in which a person's kidney cease functioning on a permanent basis leading to the need for regular course of long-term dialysis or a kidney transplant to maintain life), anemia (blood disorder), and peripheral vascular disease (reduced circulation of blood to a body part). During a review of Resident 18's History and Physical (H&P), dated 10/18/2022, the H&P 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.

Based on interview and record review, the facility failed to ensure the Infection Preventionist (a person designated by the facility to be responsible for the infection prevention and control program) Nurse attend, participate and give findings on a regular basis to Quality Assessment and Assurance ([QAA] develop and implement appropriate plans of action to correct identified quality deficiencies) committee. This deficient practice had the potential to negatively impact resident safety and unable to monitor infection control practices and outcome of the facility. Findings: During an interview on 3/7/2024 at 9:50 a.m. with IP Nurse, IP Nurse stated he works with the nursing staff to curtail (reduce in extent or quantity) infection in the facility, in charge of antibiotic stewardship program (refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use) and educate staff about proper infection control measures. IP Nurse stated he is part of the QAA committee and attends the meeting every…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to: 1. Ensure humidifier (helps to relieve respiratory symptoms such as shortness of breath) was labeled and dated for one out of five Residents (Resident 34). 2. Ensure housekeeping washed their hands after removing dirty gloves. These deficient practices had the potential to cause the spread infection. Findings: a. During a review of Residents 34's admission Record (Face Sheet), the admission Record indicated Resident 34 was initially admitted to the facility on [DATE] and readmitted to the facility 1/20/2024. Resident 34 diagnoses not limited to chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), cardiomegaly (a disease affecting the heart muscle), and metabolic encephalopathy (an alteration in consciousness caused due to brain dysfunction). During a review of Residents 34's History and Physical (H&P), dated 1/26/2024, the H&P indicated, Resident 34 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure one out of five Residents (Resident 8) was able to open the glass door in Resident 8 room. This deficient practice of the glass door not able to easily open and closing affected the ability for Resident 8 not to be able to freely exit nor enter into Resident 8 room from the outside patio. Findings: During a review of Residents 8's admission Record (Face Sheet), the admission Record indicated Resident 8 was initially admitted to the facility on [DATE] and readmitted to the facility 3/22/2021. Resident 8 diagnoses not limited to generalized muscle weakness (an overall reduced of body strength or lack of energy makes it difficult to perform activities), osteoarthritis (a clinical syndrome of joint pain accompanied by varying degrees of functional limitation and reduced quality of life), hypertensive heart disease (changes in the function of the heart as a result of chronic blood pressure elevation). During a review of Residents 8'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 conduct a baseline assessment of wounds for one out of three residents (Resident 3). This deficient practice could have potentially resulted in Resident 3 ' s wounds worsening without acknowledgement of the facility to intervene. Findings: During a review of Resident 3 ' s admission Record, dated 2/14/2024, the admission Record indicated Resident 3 was initially admitted to the facility on [DATE] with admitting diagnoses of dementia (the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and functional quadriplegia (complete immobility due to severe disability or frailty from another medical condition without injury to the brain or spinal cord). During a review of Resident 3 ' s History and Physical (H&P), dated 2/8/2024 the H&P indicated Resident 3 was nonverbal and could not communicate. During a review of Resident 3 ' s admission Screening/History, dated 2/2/2024, 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 follow its policy and procedure (P/P) titled, Abuse Prevention and Prohibition Program, to report allegation of abuse to the state survey agency, for the two of five sampled residents, (Resident 3 and Resident 4). Resident 3 who went to Resident 4 ' s room and poured/sprinkled his urine on Resident 4, who was on bed This deficient practice resulted to the delay in the investigation by the California Department of Public Health (CDPH) and placed Residents 3 and 4, and other residents at risk for continuous abuse. Findings: During a review of Resident 3 ' s admission record, the admission record indicated Resident 3 was originally admitted on [DATE] and re-admitted on [DATE] with a diagnosis including osteoarthritis (progressive, degenerative joint disease), muscle weakness (a decrease in muscle strength), and intervertebral disc degeneration (breakdown of one or more of the discs). During a review of Resident 3 ' 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 interview and record review, the facility failed to provide personal hygiene and assistance with toileting for 1 of 4 sampled residents, Resident 1. This failure had the potential to result in Resident 1 lying in soiled undergarments for several hours and causing further skin damage. Findings: During a record review of Resident 1's admission record dated 11/6/2023, the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnosis of muscle weakness, urinary tract infection (an infection in any part of the urinary system, the kidneys, bladder, or urethra), and irritable bowel syndrome (an intestinal disorder causing pain in the belly, gas, diarrhea, and constipation) without diarrhea. During a record review of Resident 1's Minimum Data Set (MDS-an assessment and care planning tool) dated 9/18/2023, indicated Resident 1 has clear speech, has the ability to express ideas and wants, and clear comprehension. The MDS indicated Resident 1 required extensive assistance 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 certified nurse assistants (CNA) failed to document accurate skin assessment for 1 of 3 residents (Resident 1) who had a pressure ulcer (injury to the skin) stage 3 (full thickness of tissue loss) on the left sacrum (triangular shaped bony structure located at the base of the spine) and an unstageable pressure ulcer (full thickness loss but is covered by dead tissue) on the right sacrum for the month of September 2023. This deficient practice had the potential to cause further skin breakdown, delay treatment and place the resident at risk for infection leading to hospitalization. Findings During a review of Resident 1 ' s admission record (Face sheet), the face sheet indicated Resident 1 was originally admitted to the facility on [DATE] and re-admitted from general acute care hospital (GACH) on 8/5/2023, with a diagnosis of osteoarthritis (degenerative joint disease), muscle weakness, and anemia (lack of red blood cells). During a review of the 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 interview and record review, the facility failed to supervise three of four sampled residents (Resident 1, Resident 2, and Resident 3) after smoking hours ended which resulted in Resident 2 sustaining an injury on the left side of the face. This deficient practice resulted in a physical altercation between Resident 1 and Resident 2, and had the potential to place other residents safety at risk. Findings: a. During a review of the Resident 1's Face Sheet (admission record), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including chronic obstructive pulmonary disease (COPD, inflammatory lung disease that causes airflow obstruction) with acute exacerbation, muscle weakness, and nicotine dependence (cigarettes). During a review of Resident 1's Minimum Data Set [(MDS) a standardized assessment and care screening tool], dated 7/6/2023, the MDS indicated Resident 1's cognitive skills (the mental action or process of acquiring knowledge and understanding through…

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 notify the physician when one out of four sampled residents (Resident 2) was exhibiting aggressive behavior due to being intoxicated and was in possession of bottles of liquor. This deficient practice had the potential to delay medical interventions if applicable for Resident 2 and put other residents as risk of the resident's aggressive behavior. Findings: During a record review of the Resident 2's Face Sheet (admission record), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with diagnosis including schizophrenia (mental disorder that affects how an individual thinks), epilepsy (seizure, sudden and uncontrolled burst of electrical activity in the brain), and a ligament disorder (short band of tough, flexible fibrous connective tissue which connects two bones or cartilages or holds together a joint) of the left wrist. During a record 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 interview and record review, the facility failed to protect two of four sampled resident's (Resident 1 and Resident 2) right to be free from verbal and physical abuse. Resident 1 and Resident 2 had a physical altercation in the smoking patio at midnight, on 8/6/2023. This failure resulted in Resident 1 and Resident 2 physically assaulting each other. Resident 2 sustained a skin abrasion on the left side of the face with skin discoloration and slight bleeding. Findings: a. During a review of Resident 1's Face Sheet (admission record), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including chronic obstructive pulmonary disease (COPD, inflammatory lung disease that cause airflow obstruction) with acute exacerbation, muscle weakness, and nicotine dependence (cigarettes). During a review of Resident 1's Minimum Data Set [(MDS) a standardized assessment and care screening tool], dated 7/6/2023, the MDS indicated Resident 1's cognitive skills (the mental action or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to do a thorough investigation for a resident-to-resident altercation for two of four sampled residents (Resident 1 and Resident 2) that resulted in Resident 2 sustaining an injury on the left side of his face. This deficient practice had the potential to place other residents at risk for abuse. Findings: a. During a review of the Resident 1's Face Sheet (admission record), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including chronic obstructive pulmonary disease (COPD, inflammatory lung disease that cause airflow obstruction) with acute exacerbation, muscle weakness, and nicotine dependence (cigarettes). During a review of Resident 1's Minimum Data Set [(MDS) a standardized assessment and care screening tool], dated 7/6/2023, the MDS indicated Resident 1's cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) were intact. The MDS…

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 the care plan for three of four sampled residents (Resident 1, Resident 2, Resident 3). The care plan interventions were not implemented regarding Resident 1, Resident 2, and Resident 3's smoking habits, and the care plan interventions were not implemented addressing Resident 2's aggressive behavior towards staff and residents. This failure resulted in Residents 1, 2, and 3 hanging out in the smoking patio unsupervised, at midnight. Resident 1 and Resident 2 had a physical altercation resulting in Resident 2 sustaining an injury to the face. Findings: a. During a review of the Resident 1's Face Sheet (admission record), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including chronic obstructive pulmonary disease (COPD, inflammatory lung disease that cause airflow obstruction) with acute exacerbation, muscle weakness, and nicotine dependence (cigarettes). During a review of Resident 1's Minimum Data…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility staff failed to maintain complete and accurate medical records in accordance with accepted professional standards for two of three residents (Resident 2 and Resident 3) by failing to ensure the Controlled Drug Record ([CDR], charting each dose of narcotic medication administered) and Medication Administration Record (MAR) was complete and accurately documented for Residents 2 and 3. This deficient practice had the potential to result in medication error, medication overdose or hospitalization for Residents 2 and 3. Findings: During a review of Resident 2's admission Record (Face sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included idiopathic peripheral autonomic neuropathy (damage of the nerves), pain left hip and other intervertebral disc degeneration lumbar region (loss of disc space, and compression and irritation of the adjacent nerve root). During a review of 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 interview and record review, the facility failed to follow its Policy and Procedure (P&P) to resolve one of three sampled residents ' (Resident 3) grievance regarding missing clothing at the facility. This deficient practice had the potential to negatively affect the resident ' s psychosocial wellbeing. Findings: During a review of Resident 3 ' s admission Record (Face sheet), the Face Sheet indicated Resident 3 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included phantom limb syndrome with pain (the perception of pain or discomfort in a limb that was no longer there ) polyarthritis (inflammation and pain affecting five or more joints are affected) and muscle weakness (commonly due to lack of exercise, aging or muscle injury). During a review of Resident 3 ' s Minimum Data Set ([MDS], a standardized assessment and care screening tool), dated 7/7/2023, the MDS indicated Resident 3 was able to understand and be understood by others. The MDS also indicated 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: a. Ensure the facility followed its Policy and Procedure (P&P) for narcotic reconciliation (system of ensuring accurate inventory of medications by accounting for controlled medications that have been received, dispensed, administered and/or, process of disposition) at the change of shift on ten shifts. b. Ensure the facility administered Restoril (medication to help with sleep) for one of 3 sampled residents (Resident 1) according to the physician ' s order. These deficient practices had the potential for diversion (illegal distribution or abuse of prescription or controlled drugs) and inability to sleep for Resident 1 Findings: a. During a review of the shift changes narcotic reconciliation records dated 6/2023, 7/2023, and 8/2023 titled, Narcotic Key Control, the records indicated missing licensed nurse signatures on the signature box for the off-duty nurse on the following shifts: 6/2/2023 day shift, 6/2/2023 evening shift, 6/17/2023…

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 safe and sanitary food storage and preparation practices were followed in the kitchen by failing to ensure dietary staff wore hair restraint (coverings or nets designed and worn to keep hair from contacting food, clean equipment, and utensils) in the kitchen. This deficient practice had the potential to lead to cross contamination of food and clean equipment which could cause food borne illness to facility residents. Findings: During a concurrent observation and interview on 8/8/2023 at 8:24 a.m. at the kitchen, Kitchen Aid (KA) was observed not wearing a hair restraint. KA stated her duties included cleaning, washing dishes, make cookies, refilling milk, and helped prepare food for the residents. KA stated, her hair net broke at the start of the shift and had forgotten to put a new one on. KA also stated hair nets were always required in the kitchen to ensure proper hygiene while preparing food for residents and to prevent hair from falling into food or coffee which could cause residents to become…

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.