Rosecrans Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the cultural and ethnic needs of food choices were identified for one of five sampled residents (Resident 107).This deficient practice placed Resident 107 at risk for being dissatisfied with meals.Findings:During a review of Resident 107's admission Record, the admission Record indicated Resident 107 was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia (a severe, chronic mental health condition where a patient experiences a loss of touch with reality), dementia (a progressive state of decline in mental abilities), and diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 107's History and Physical (H&P), dated 3/19/2026, the H&P indicated Resident 107 did not have the capacity to make medical decisions.During a review of Resident 107's Minimum Data Sheet (MDS, a resident assessment tool), dated 4/17/2026, 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.

Based on interview and record review, the facility failed to ensure the Infection Preventionist attended the February 2026 and May 2026 Quality Assurance and Performance Improvement (QAPI, a data driven proactive approach to improvement used to ensure services are meeting quality standards) meetings.This failure resulted in the facility not meeting the minimum required members for the monthly committee meeting.Findings:During a record review of the Monthly QAPI Meeting attendance sheets dated 2/20/2026 and 5/22/2026, the QAPI Meeting attendance sheets indicated there was no signature for the infection preventionist (IP).During a concurrent interview and record review on 6/5/2026 at 11:06 a.m. with the Administrator (ADM) and the Director of Nursing (DON), in the DON's office, the QAPI meeting attendance sheets for the 2/20/2026 and 5/22/2026 meetings were reviewed. The attendance sheets indicated there was no signature for the IP. The ADM stated the IP did not attend the meetings on 2/20/2026 and 5/22/2026. The ADM stated the minimum staff in attendance for QAPI meetings were the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the perma-catheter (a long, flexible tube inserted into a large vein and threaded near the heart) was maintained in a clean and sanitary manner for one of five sampled residents (Resident 2).This deficient practice had the potential for Resident 2 to develop an infection.Findings: During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnoses included stage three pressure ulcer (full thickness loss of skin. Dead and black tissue may be visible), diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), and end stage renal disease (the final, permanent stage when the kidneys can no longer filter wase and fluid s from the blood to sustain life).During a review of Resident 2's History and Physical (H&P), dated 3/19/2026, the H&P indicated Resident 2 did not…

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 a residents' responsible party (RP) of a change in condition for one of three sampled residents (Resident 3).This deficient practice had the potential to violate Resident 3's RP's rights to be informed of changes to the plan of care.Findings:During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 3's diagnoses included diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), pressure ulcer of the sacral region (directly over tailbone), Stage Four (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) and chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing).During a review of Resident 3's History and Physical (H&P) dated 1/14/2026, the H&P indicated Resident 3 was non-verbal and did not have 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 document behavioral interventions as indicated on the care plan for one of two sampled residents (Resident 1) following an altercation with Resident 2.This failure had the potential to result in continued behavioral escalation and increased risk of physical harm to other residents.Findings:During a record review of Resident 1's admission Record (Face sheet), the admission Record indicated the facility admitted the resident on 12/10/2025 with diagnoses including anemia (low blood cells in body) and schizoaffective disorder (mental health disorder affecting how a person thinks and acts).During a record review of Resident 1's progress note dated 2/28/2026, the progress note indicated Resident 1 was transferred out for 5150 (a law code that allows a person in a mental health crisis to be taken to a hospital or mental health facility against their will) for danger to others.During a record review of Resident 2's admission Record, (Face sheet), the admission Record indicated the facility admitted the resident on 2/14/2026 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 observation, interview, and record review the facility failed to:1. Ensure one out of three sampled residents (Resident 1) unwitnessed injury to the left eye was reported to California Department of Public Health (CDPH).This deficient practice of not reporting to CDPH within 24 hours of an unwitnessed injury resulted in discoloration (a localized area of altered skin color that indicates underlying tissue damage) to the left eye. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses metabolic encephalopathy (an acute or chronic alteration in brain function), epilepsy (a chronic neurological disorder characterized by recurrent, unprovoked seizures), dementia (a progressive state of decline in mental abilities), and muscle weakness (a reduction in the ability to generate normal force in muscles, often presenting as impaired physical mobility, fatigue, or decreased functional…

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

Based on observation, interview and record review, the facility failed to implement their policy and procedure (P&P) titled, Refrigerators and Freezers which indicated to monitor and record the refrigerator and freezer temperatures daily, for 3 of 3 refrigerators and 2 of 2 freezers.This failure had the potential to cause food spoilage (the deterioration of food due to various factors, resulting in an undesirable change in its appearance, taste, texture, or nutritional value) and lead to foodborne illnesses (any illness caused by consuming foods or beverages contaminated with harmful bacteria, viruses and parasites or their toxins [poisonous substances produced by organisms like bacteria that harm the body]).Findings:During a concurrent interview and record review on 01/05/2026 at 11 a.m., with the Dietary Supervisor (DS), in the kitchen, the refrigerator and freezer temperature logs dated 2026, were reviewed.The refrigerator temperature logs for the following days were blank and did not indicate monitoring was completed:On 1/1/2026 and 1/2/2026 for Produce and Breads, Milk and…

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

Based on observation, interview and record review, the facility failed to implement its infection prevention and control measures for one of two shower rooms (east shower room), by failing to ensure the shower floor and wall were clean and disinfected from fecal matter (the solid waste passed out of the body of a human through the bowel). This failure had the potential to spread bacteria and germs that could lead to infection for facility residents. Findings:During a concurrent observation and interview on 01/05/2026 at 11:39 a.m., with the housekeeper (HK 1), in the east shower room, dry brown fecal matter was observed on the wall of the 2nd shower stall, and a small drop of brown feces was observed on the floor. HK 1 stated failure to clean and disinfect the walls and floors may increase the risk of residents getting sick.During a review of the facility's Job Description titled, Housekeeper, dated 09/2025, the Job Description indicated the primary purpose of this position is to perform the day-to-day activities of housekeeping as directed by the housekeeping supervisor to assure…

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 privacy during care for three of eight residents (Residents 2, 3, and 4) when certified Nursing Assistants (CNA) 1, CNA 2, and CNA 3 did not fully close the privacy curtains while providing care. This failure had the potential to affect the dignity and self-worth of Residents 2, 3, and 4. Findings: a. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 8/15/2025 with diagnoses including generalized muscle weakness, difficulty in walking, lymphedema (tissue swelling caused by an accumulation of protein-rich fluid that's usually drained through the body's lymphatic system), and morbid obesity (severely overweight). During a review of Resident 2's History and Physical (H&P), dated 9/1/2025, the H&P indicated, Resident 2 had the capacity to make decisions. During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool), dated 8/19/2025, 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 notify one of four sampled residents (Resident 1), at least 30 days prior to the resident's discharge plan on 7/19/2025, as indicated in the facility's policy and procedure (P&P) titled, Transfer and Discharge Notice.This deficient practice resulted in Resident 1 not being aware of the discharge plans and had the potential to affect the resident's highest practicable physical, mental and psychosocial well-being. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including muscle weakness, abnormalities of gait and mobility (deviations from the typical manner of walking) and atrial fibrillation (irregular heartbeat.) During a review of Resident 1's History and Physical (H&P) dated 6/26/2025, the H&P indicated Resident 1 had the mental capacity to understand and make medical decisions. During a review of Residents 1'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 ensure one of four sampled residents (Residents 2), was not trapped in Resident 1's room on 7/15/2025 at 4:00 a.m. This failure had the potential to cause resident to resident altercation and resident injuries, leading to hospitalization.1). 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 muscle weakness, abnormalities of gait and mobility (deviations from the typical manner of walking,) and Atrial Fibrillation (irregular heartbeat.)During a review of Resident 1's H&P dated 6/26/2025, the H&P indicated Resident 1 had the mental capacity to understand and make medical decisions.During a review of Resident 1's MDS dated [DATE], the MDS indicated Resident 1 had intact cognition. The MDS indicated Resident 1 required supervision or touching assistance with ADLs such as dressing, toilet use, personal hygiene, transfer and mobility.During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to monitor for signs and symptoms of bleeding and bruising related to the use of aspirin (a medication used to prevent blood clots) and Eliquis (a medication used to prevent blood clots) between 4/1/25 and 4/24/25 in one of five residents sampled for unnecessary medications (Resident 82). The deficient practice of failing to monitor for signs and symptoms of bleeding during aspirin and Eliquis therapy increased the risk that Resident 82 could have experienced adverse effects (unwanted and dangerous side effects of medication) such as bleeding and bruising leading to medical complications requiring hospitalization. Findings: During a review of Resident 82's admission Record (a record containing diagnostic and demographic resident information), dated 4/24/25, indicated he was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis and muscle weakness in 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. Label one opened vial of latanoprost (a medication used to treat eye conditions) eye drops with an open date affecting Resident 16 in one of two inspected medication carts (East Medication Cart). 2. Store lorazepam oral solution (a medication used to treat mental illness) in the refrigerator per the manufacturer's requirements affecting resident 410 in one of two inspected medication carts (East Medication Cart). 3. Store gabapentin oral solution (a medication used to treat nerve pain) in the refrigerator per the manufacturer's requirements affecting resident 410 in one of two inspected medication carts (East Medication Cart). 4. Label one open fluticasone/salmeterol inhaler (a medication used to treat breathing problems) with an open date affecting Resident 411 in one of two inspected medication carts (East Medication Cart). 5. Label one open Lantus insulin pen (a medication used to treat high blood sugar) with an open date affecting…

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 of one sample residents (Resident 30) had an intravenous (IV- a thin flexible tube inserted into the vein used to draw blood and give treatments) catheter with the date of insertion on it. This deficient practice had the potential for Resident 30's IV site to go unchanged which could lead to an infection. Findings: During an observation on 11/22/2025 at 11:00 a.m. Resident 30 was observed lying in bed with an IV catheter inserted to the left wrist with no date on the outer dressing of the IV. Resident 30 was receiving IV fluids through the IV catheter inserted to the left wrist. During a review of Resident 30's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 30 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included chronic kidney disease (a condition where the kidneys are damaged and can't filter blood as…

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 of three sampled residents (Resident 82) had their oxygen saturation level (O2 sat- a measurement of how much oxygen the blood is carrying as a percentage) checked every shift as ordered. This deficient practice had the potential for Resident 82 to be receiving too much or too little oxygen and could lead to difficulty in breathing. Findings: During an observation on 4/22/2025 at 11:13 a.m., Resident 82 was observed in bed and had a nasal cannula (a device that delivers extra oxygen through a tube into your nose) on with oxygen at 2 liters per minute (lpm- flow of oxygen per minute). During a review of Resident 82's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 82 was admitted on [DATE] with diagnoses that included dependence on supplemental oxygen (a medical treatment that provides extra oxygen to a person), cardiomegaly, and myocardial…

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 manage a resident ' s pain (Resident 1) after the resident complained of pain to the licensed nurse. This failure resulted in Resident 1 experiencing unrelieved pain and had the potential to interfere with activities of daily living (ADLs). Findings: During a review of Resident 1 ' s admission Record (front page of the chart that contains a summary of basic information about the resident), the admission record indicated the facility admitted Resident 1 on 10/10/2024, with diagnoses including polyneuropathy (disease or dysfunction of one or more nerves, typically causing numbness or weakness in the hands and feet), repeated falls, and diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of the Minimum Data Set (MDS - a resident assessment tool) dated 1/13/2025, the MDS indicated Resident 1 had the ability to express ideas and wants and the ability to understand others. The MDS also indicated Resident 1 had no impairment in the upper extremities…

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 wound dressings for two of three sampled residents (Resident 1) were labeled with the nurse's initials, time, and date. This failure had the potential to result in wound dressings not being changed, resulting in wound infections and delayed wound healing. Findings: 1.During 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]. The admission Record indicated Resident 1's diagnoses included stage 4 pressure ulcer (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) of the sacral (lower back) region, quadriplegia (paralysis from the neck down, including legs, and arms due to severe physical disability or frailty), and diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 1's Minimum Data Set (MDS – a 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 implement its policy and procedure (P&P) titled, Enhanced Standard Precautions ([ESP] a framework for reducing multi drug-resistant organism [MDRO] transmission by using gowns and gloves while caring for residents at high risk for MDRO transmission, at the point of care during specific activities, by contmainating health care workers' hands, clothes and the environment), which indicated to don (put on) PPE within room, before engaging in activity (resident care), if splash is anticipated, for two of eight sampled residents (Residents 6 and 7), who had physician ' s orders for wound care. This deficient practice had the potential to result in transmission of a disease-causing organisms, affecting the other residents in the facility, and the potential for the affected residents ' delay in wound healing process. Findings: 1). During a review of Resident 6 ' s admission Record, the admission Record indicated Resident 6 was originally admitted…

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 clean linens were not placed near the facility's washing machines where dirty and soiled clothing was stored. This deficient practice placed clean linens at risk for bacteria (small single-celled organisms that cause infection) and had the potential for cross contamination and spread of infection throughout the facility. Findings: During an observation on 4/18/2024 at 12:15 p.m. in the facility's laundry room, there were 11 linen carts filled with clean linen and placed alongside of three washing machines with dirty linen washing inside. During a concurrent observation and interview on 4/18/2024 at 12:20 p.m. in the laundry room with the Housekeeping Supervisor (HS), the HS the 11 linen carts placed by soiled linen were clean and will be distributed to the residents throughout the facility. The HS stated having the clean linen close to the washing machines with soiled linen will put residents at risk infection and could spread throughout the facility. During a concurrent observation and interview on 4/18/2024 at 12:45…

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 staff promoted dignity while assisting one of two residents (Resident 56) during meals by standing over the resident and not maintaining face to face eye contact. This deficient practice had the potential to result in feelings of decreased self-esteem and self-worth for Resident 56. Findings: During a review of Resident 56's admission Record, the admission Record indicated Resident 56 was admitted to the facility on [DATE]. Resident 56's diagnoses included epilepsy (a chronic disorder of the brain characterized by recurrent brief episodes of involuntary movement that may involve a part of the body or the entire body), chronic obstructive pulmonary disease (COPD, lung disease that causes blocked airflow from the lungs), schizoaffective disorder (a mental disorder with symptoms of hallucinations or delusions and mood disorder like depression) and major depressive disorder (a mental health condition that causes a persistently low…

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 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 three sampled residents (Resident 56). This deficient practice violated the residents' right to make an informed decision regarding the use of psychoactive medications. Findings: During a review of Resident 56's admission Record, the admission Record indicated Resident 56 was admitted to the facility on [DATE]. Resident 56's diagnoses included epilepsy (a chronic disorder of the brain characterized by recurrent brief episodes of involuntary movement that may involve a part of the body or the entire body), chronic obstructive pulmonary disease ([COPD] a lung disease that causes blocked airflow from the lungs), schizoaffective disorder (a mental disorder with symptoms of hallucinations or delusions and mood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, and interview the facility failed to ensure one of 20 sampled residents (Resident 6) was provided a safe, clean and homelike environment by failing to provide a room that did not have soiled or peeling paint on the bedroom walls. This deficient practice had the potential for Resident 6 to be exposed to dirt, harsh chemicals, infection and accidents. Findings: During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was admitted to the facility on [DATE]. Resident 6's diagnoses included Type 2 diabetes mellitus (abnormal blood sugar), heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs), and anxiety disorder (persistent and excessive worry that interferes with daily activities). During a review of Resident 6's history and physical (H&P), dated 10/3/2023, the H&P indicated Resident 6 did not have the capacity to understand and make decisions. During a review of Resident 6'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 ensure an accurate Minimum Data Set ([MDS] assessment and care screening tool) assessment regarding the pneumococcal vaccine (a biological preparation that prevents the most common and severe forms of pneumonia [lung infection]) was conducted for one of five sampled residents (Resident 75). This deficient practice had the potential to result inaccurate care and services for Resident 75 due to inappropriate MDS care screening and tool assessment practices. Findings: A review of Resident 75's admission Record, indicated Resident 75 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 75's diagnoses included end stage renal disease ([ESRD] a condition in which the kidneys no longer function normally), diabetes mellitus type 2 ([DM] a chronic condition that affects the way the body processes blood sugar), and heart failure (the heart is unable to pump blood around the body properly). A review of Resident 75'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 complete and re-submit the Preadmission Screening and Resident Review ([PASRR] a tool to determine if the person had, or was suspected of having a mental illness, intellectual disability [a term used when a person has certain limitations in cognitive functioning and skills, including communication, social and self-care skills], or related condition) level one (I) screening and refer one of eight sampled residents (Resident 22) who had a new diagnosis of psychosis (collection of symptoms that affect the mind, where there has been some loss of contact with reality) to the appropriate state-designated authority for a PASRR level two (II) evaluation and determination. This deficient practice had the potential to result in Resident 22 not receiving appropriate treatment recommendations for psychosis. Findings: A review of Resident 22's admission record, indicated, Resident 22 was originally admitted to the facility on [DATE] and readmitted 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, interviews and record review, the facility failed to initiate a care plan for Restorative Nursing Assistant ([RNA] assist the patient in performing tasks that restore or maintain physical function as directed by the established care plan) services for one out of four (4) residents' (Resident 74). This deficient practice had the potential to negatively affect the delivery of necessary care and services. During a review of Resident 74's admission record (face sheet), the admission record indicated Resident 74 was initially admitted to the facility on [DATE], with diagnoses that included ataxia (poor muscle control that causes clumsy movements), muscle weakness (decreased strength in the muscles), repeated falls (more than two falls in a six-month period), and cardiomegaly (an enlarged heart). During a review of Resident 74's Minimum Data Set (MDS- assessment and care screening tool), dated 1/17/2024, indicated the resident was assessed to be cognitively intact and required supervision with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one out of four Residents (Resident 43) had a revised care plan to implement an order for a back brace (a device designed to limit the motion of the spine) for support. This deficient practice placed Resident 43 at risk, for providing back support, and had the potential to cause immobility, unsteady gait, and increased back pain. Findings: During a review of Resident 43's admission Record (Face Sheet), the admission Record indicated Resident 43 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included low back pain (pain between the lower edge of the ribs and the buttock), muscle spasm (a muscle cramp is an uncontrollable and painful of a muscle), and myalgia(soreness and aches in the muscles that can range from mild to severe). During a review of Resident 43's History and Physical (H&P), dated 9/22/2023, the H&P indicated Resident 43 could understand and make their own medical decisions. 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 oral hygiene (cleaning the mouth and tongue) for one of 20 sampled residents (Resident 92). This deficient practice resulted in Resident 92 having poor oral hygiene with the presence of thick yellowish particles on the mouth and tongue that could lead to an oral infection. Findings: A review of Resident 92's admission record, indicated Resident 92 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 92's diagnoses included cerebral infarction (damage to tissues in the brain due to loss of oxygen to the area) with hemiplegia (weakness) and hemiparesis (inability to move on one side of the body), hypertension ([HTN] high blood pressure), and diabetes mellitus ([DM] a chronic condition that affects the way the body processes blood sugar). A review of Resident 92's History and Physical (H&P), dated 4/17/2024, indicated Resident 92 did not have the capacity to understand and make decisions. A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide one of three residents (Resident 3) her preferred activity to stay in the dining recreation area to participate in group activity. This deficient practice had the potential to decrease Resident 3's social interaction, sense of belongings, depression, and emotional health. Findings: During a review of Resident 3's admission record, the admission Record indicated, Resident 3 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 3's diagnoses included cerebral infarction (damage to tissues in the brain due to loss of oxygen to the area) with hemiplegia (weakness) and hemiparesis (inability to move on one side of the body), diabetes mellitus ([DM] a chronic condition that affects the way the body processes blood sugar), and epilepsy (a brain condition that causes recurring seizures). During a review of Resident 3's History and Physical (H&P), dated 3/11/2024, the H&P indicated, Resident 3 did not have…

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 of nine sampled residents (Resident 22), with a limited range of motion, was provided with a left hand roll (a device that prevents fingers from curling up tightly) as ordered by the physician. This deficient practice had the potential to result in further decline in range of motion and worsening of contracture (decrease in passive range of motion at a joint) for Resident 22. Findings: A review of Resident 22's admission record indicated Resident 22 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including osteoarthritis (a degenerative joint disease in which the tissues in the joint break down over time), contractures, and dementia (loss of cognitive functioning, thinking, remembering, and reasoning). A review of Resident 22's care plan titled, Resident at risk for pain due to use or application of hand roll to affected extremity, dated 6/15/2021, indicated Resident 22's goal was 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 a resident who received hemodialysis ([HD] process of removing waste products and excess fluid from the body) received treatment in accordance with standards of practice for one of two sampled residents (Resident 75) by failing to: 1. Ensure the HD emergency kit (E-Kit) was always available at bedside for safety measures for HD complications. 2. Communicate to Resident 75's physician regarding the recommendation of dialysis treatment center staff to limit fluid restriction to 32 ounces ([oz] measures volume) per day. These deficient practices had the potential to result in staff inability to manage bleeding from Resident 75's dialysis access site in the event of emergency and risk for fluid overload, swelling, shortness of breath and discomfort. Findings: A review of Resident 75's admission Record, indicated Resident 75 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 75's diagnoses included end…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two medications were labeled with medication open dates for two of two sampled residents (Resident 13 and 77) and to follow manufacturer's guidelines when foil was opened for budesonide inhalation suspension (medication to help with breathing) for Resident 77. This failure had the potential to result in the loss of medication potency and for residents to receive ineffective medication dosages. Findings: During a review of Resident 13's admission Record, indicated the resident was admitted to the facility on [DATE] and readmitted [DATE] with the diagnoses including chronic obstructive pulmonary disease ([COPD] disease that effects the lungs) and dependence on supplemental oxygen. During a review of Resident 13's Order Summary report dated [DATE], the order summary report indicated Resident 13 was on Spiriva hand inhaler (medication used to help with breathing), one inhalation orally one time a day. During a review of Resident 77'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 ensure one out of four Residents (Resident 43) had a back brace ordered by the physician to alleviant (relieve) back pain. This deficient practice did not provide Resident 43 with a back brace to help alleviate back pain and had the potential to place Resident 43 of having increased back pain. Findings: During a review of Resident 43's admission Record (Face Sheet), the admission Record indicated Resident 43 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included low back pain (pain between the lower edge of the ribs and the buttock), muscle spasm (a muscle cramp is an uncontrollable and painful of a muscle), and myalgia(soreness and achiness in the muscles that can range from mild to severe). During a review of Resident 43's History and Physical (H&P), dated 9/22/2023, the H&P indicated, the Resident 43 can understand and make their own medical decisions. During a review of Resident 43's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one out of five sampled residents (Resident 75) was offered the pneumococcal vaccine ([PNA] a vaccine that prevents the most common and severe forms of pneumonia [ infection of the lung]). This deficient practice placed Resident 75 at higher risk of acquiring pneumonia. Findings: A review of Resident 75's admission Record, indicated Resident 75 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 75's diagnoses included end stage renal disease ([ESRD] a condition in which the kidneys no longer function normally), diabetes mellitus type 2 ([DM] a chronic condition that affects the way the body processes blood sugar), and heart failure (the heart is unable to pump blood around the body properly). A review of Resident 75's History and Physical (H&P), dated 11/6/2023, indicated Resident 75 had the capacity to understand and make decisions. A review of Resident 75's Minimum Data Set ([MDS] an 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 follow its Administrative Manual titled, Elder/ Dependent Abuse, which indicated to report any allegations of abuse or that results in serious bodily injury, to the State Survey agency, immediately but not later than two hours, for one of three residents (Resident 1). Resident 1 sustained a baseball size (a regulation baseball is 9 to 9.25 inches in circumference) bruise (discolored skin) on her right upper forearm. Resident 1 sustained right upper arm bone fracture (broken bone). This deficient practice delayed the investigation by the California Department of Public Health (CDPH). Findings: During 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] with diagnoses that included quadriplegia, contracture of right hand, and aphasia (inability to communicate). During a review of Resident 1 ' s History and Physical (H&P), dated 10/23/2023, 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 three of four sampled residents (Resident 2, Resident 3, and Resident 4) who had long rough edges toenails, received foot care and treatment. This deficient practiced placed Residents 2, 3 and 4 at risk for infection of the toenails, pain, and injury. Findings: a. During a review of Resident 2 ' s admission Record (Face Sheet), the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including parkinsonism (brain conditions which causes slowed movements, stiffness, and tremors), diabetes ([DM] high blood sugar), and muscle weakness. During a review of Resident 2 ' s Minimum Data Set ([MDS] a standardized care assessment and care screening tool), dated 11/19/2023, the MDS indicated Resident 2 required substantial/ maximal assistance (staff lifts or holds trunk or limbs and provided more than half of the effort) to total dependence on staff for activities of daily living (ADLs) such as dressing,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement its infection prevention and control policy and procedure (P&P) by failing to ensure staff properly donned (put on) a facemask (protective covering to help prevent spreading of germs and diseases) while in the facility and in resident care areas. This failure had the potential for the spread of transmissible diseases amongst staff, residents, and visitors. Findings: During observations on 1/30/2024 at around 10:09 a.m., the following were observed: 1.Certified Nurse Assistance (CNA) 1 exited room [ROOM NUMBER] and walked down the hallway with her surgical mask down to her chin. 2.CNA 2 was exited room [ROOM NUMBER] and walked to the nurse station without a mask. 3.Activity Director (AD) was standing next to a resident in the activity room wearing a surgical mask on her chin. 4.Restorative Nurse Assistance (RNA) assisted a resident in her wheelchair wearing a mask down to her chin During an interview on 1/30/2024 at 1:10 p.m.,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow its policy and procedure (P/P) titled Enteral (passing through the intestine, either naturally via the mouth and throat, or through an artificial opening) Feedings-Safety Precautions which indicated to elevate the head of a resident's bed (HOB) at least 30° during tube feeding (gastrostomy [GT] when a tube is inserted through the stomach to administer food and medication) for 1 of 4 sampled residents (Resident 2). This deficient practice had the potential to result in aspiration (when a person swallowed something and it entered the lungs instead of the stomach), difficulty breathing and death. Findings: During a review of Resident 2's admission record dated 9/20/2023, the admission record indicated Resident 2 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnosis including dementia (a group of thinking and social symptoms that interferes with daily functioning), dependence on supplemental oxygen,…

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 Lab and Diagnostic Test Results-Clinical Protocol, which indicated the physician will order diagnostic and laboratory tests based on each resident's condition and nurses will identify the urgency of communicating with the physician based on the request, the seriousness of an abnormal result or the resident's current condition, for 1 of 4 sampled residents (Resident 1). This deficient practice had the potential to cause Resident 1 to bruise and bleed. Findings: During a review of Resident 1's admission record indicated Resident 1 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnosis including anemia (not enough healthy red blood cells in the body), hypertension (high blood pressure), and Alzheimer's disease (a brain disorder that causes a gradual decline in memory, language loss, and impaired judgment). During a review of Resident 1's Minimum Data Set (MDS-an assessment…

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

Based on observation, interview, and record review, the facility failed to: 1. Maintain accountability of 14 doses of controlled substances (narcotics, medications with a high potential for abuse) located the in the emergency kit (e-kit), affecting all 99 residents within the facility. 2. Ensure emergency narcotics were available in the event narcotic medications are ordered by a physician for severe pain, possible seizure (burst of uncontrolled electrical activity between brain cells) or acute coronary syndrome (range of conditions related to sudden, reduced blood flow to the heart) for all 99 of the residents. 3. Notify local authorities and the Drug Enforcement Agency (DEA) regarding 14 missing doses of controlled substances, affecting all 99 residents within the facility. 4. Securely store nine medication cards (a bubble pack from the dispensing pharmacy labeled with the resident's information that contains the individual doses of the medication) containing unused controlled substances as required by the facility's policy and procedure for eight out of 12 sampled residents…

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.