Golden Haven Care Center

Based on interview and record review, the facility failed to obtain laboratory test as ordered by the physician for one of three sampled residents (Resident 67) who was ordered by Physician (Attending Physician) 1 to obtain urinalysis (urine test to determine presence of infection or other kidney disorder) urine culture (a urine test to identify if bacteria was growing in the urine) after Resident 67 complained of dysuria (painful, burning, or discomfort when urinating) on 1/7/2026. The urinalysis and urine culture test were obtained eight (8) days since the physician ordered the laboratory test after the facility was informed that there was no laboratory test obtained for Resident 67. As a result of this deficient practice Resident 67 did not receive the antibiotic (medication used to treat infection) resulting in continued to experience of burning sensation and a potential to have worsened UTI, permanent kidney damage, hospitalization, and death. Findings: During a review of Resident 67's admission Record (AR), the facility admitted Resident 67 8/21/2025 and readmitted 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 observations, interviews, and record reviews, the facility failed to develop a resident centered care plan for one of three sampled residents (Resident 1) after the facility identified a safety concern in which Resident 1's Responsible Party (RP) 1 was observed utilizing the Hoyer lift (a mechanical device used to lift and/or transfer a person) without calling staff for assistance to transfer Resident 1 from the bed to the chair. This deficient practice had the potential for Resident 1's specific care needs and treatment to not be addressed and had the potential for Resident 1 to sustain falls due to unsafe transfers in and out of bed. During a record review of the admission record (AR) dated 12/7/2025, the AR indicated Resident 1 was admitted to the facility on [DATE] with medical diagnoses that included muscle wasting (weakening, shrinking, and loss of muscle), Abnormal posture (involuntary/rigid body positioning), unspecified dementia (a progressive state of decline in mental abilities). 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 ensure one out of seven sampled residents ( Resident 7) was provided a funtioning call light. This deficient practice had the potential to result in a delay in care and untimely response for Resident 7. Findings: A review of Resident 7 ' s admission Record indicated the resident was admitted to the facility on [DATE], with a diagnosis that included Dysphagia (difficulty with verbal communication) and Anxiety ( feelings of being worried or nervous). A review of Resident 7 ' s Minimum Data Set ( MDS, a resident assessment tool) dated 05/13/2025, indicates resident has moderate cognitive impairment ( decline in memory, attention, language, function) and requires moderate assistance ( helper does more that half the effort ) for activities of daily living such as oral hygiene, toileting hygiene, and dressing. A review of Resident 7 ' s Care Plan Titled Ophthalmology Consult, dated 05/07/2025, indicated a goal for Resident 7 to not have any…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three residents reviewed (Resident 1), who was receiving Quetiapine (a medication used to treat bipolar disorder [a mental disorder that results in severe sadness and manic or extreme joy or elated behavior) was monitored for the specific behavior of paranoid delusions (false beliefs that someone is being threatened or mistreated) as indicated for use of the medication. This deficient practice placed Resident 1 at risk unnecessary use of medication and for mismanagement of her mental disorder and expose her to potential side effects associated with taking Quetiapine, such as drowsiness that could lead to accidents and falls. Findings: A review of Resident 1 ' s admission Record indicated the resident was admitted on [DATE] with diagnoses that included schizophrenia (a mental illness that is characterized by disturbances in thought), mood disorders, and dementia (a progressive state of decline in mental abilities). A review of Resident 1 '…

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 three sampled residents (Resident 19, 1, and 20) had that their medical records updated to show documentations that: 1. Resident 19, Resident 20, or their Responsible Party (RP) were offered and explained on how to execute an Advance Directive (a written statement of a person ' s wishes regarding medical treatment made to ensure those wishes were carried out should the resident be unable to communicate them to the doctor). 2. Resident 1 and 20 ' s had a Physician Order Life Treatment (POLST, a portable medical order form that records the resident ' s treatment wishes so that emergency personnel know what treatments the resident wants in the event of a medical emergency) had a physician ' s signature. These failures had the potential to cause conflict with the resident ' s wishes regarding the alternatives in the provision of health care and the failure to convert the resident ' s wishes regarding life-sustaining treatment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow and implement the facility ' s Policies and Procedures (P&P) titled, Change of Condition Notification, revised [DATE], for one of three sampled residents (Resident 77) with diagnoses of chronic obstructive pulmonary disease exacerbation (COPD, worsened and severe symptoms of a lung disease characterized by poor airflow to the lungs that results in shortness of breath, and respiratory distress (a condition that occurs when the body needs more oxygen than it's getting, leading to difficulty breathing, rapid breathing, and low blood oxygen levels) and a history of pneumonia (a severe respiratory infection that results in shortness of breath and difficulty breathing) by failing to: 1. Ensure to notify the physician and 911 (an emergency number) emergency services immediately, when Resident 77 complained of not being able to breath and exhibited signs and symptoms of respiratory distress, labored breathing (take more efforts to breath)…

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 treatment and services to care for two of three sampled residents (Resident 65 and Resident 36) with indwelling catheter (a thin, flexible tube inserted into the bladder to drain urine and left in place for a set amount of time). Resident 65 and 36 with indwelling catheter was observed with presence of sediments (particles free floating in urine that could be sign of infection) in the urine that was not assessed, documented and reported to the physician. These failures had the potential to result in a delay in treatments, interventions, and services to treat a possible UTI (an infection in the urinary tract- urethra, bladder, utterer and kidney), which could lead to a resident ' s increased confusion, sepsis (a life-threatening blood infection), hospitalization, and possibly death. Findings: 1. During a review of Resident 65 ' s admission Record, the facility admitted Resident 65 on 2/2/2024 and readmitted Resident 65…

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 nurse staffing information was posted in a highly visible and prominent place that was readily accessible to residents, staff, and visitors daily. This failure had the potential to result in residents and visitors not being able to access full view the facility's staffing information to ensure safe staffing sufficient staffing were implemented. Findings: During an observation on 12/3/2024 at 8:30AM in the front lobby, there was no nurse staffing information posted by the receptionist's desk. During an observation on 12/3/2024 at 9:00AM in Nursing Station 1, 2, and 3, there was no nurse staffing information posted with each Nursing Station. During a concurrent observation and interview on 12/6/2024 at 6:50 PM with the Director of Staff Development (DSD), the facility's nurse staffing information was posted next to the facility's shadow box frame by the main entrance that contained important facility documents not limited to the facility's business license and administrator's license, not easily…

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 safely and properly store medications and biologicals that were labeled and not expired in one of two medicaton cart and one on one medicaton room observed in accordance with the facility ' s policy and procedure titled Medications Storage in the Facility by failing to: 1. Remove thirteen (13) pieces of expired Tylenol Suppositories (a pain reliever and fever reducer medication that is designed to be inserted into the anus) from the shelf in the Medication Storage Room in Station 1. 2. Remove an expired container filled with Ondansetron HCL (a drug to treat nausea and vomiting) oral tablet 4 milligrams (unit of mass) from the Medication Cart 2. 3. Remove nine (9) pieces of expired N95 face masks (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of diseases acquired from the air) from the Medication Cart 2. 4. Label an opened Lidocaine cream (a medication to treat pain) with an open…

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 develop a system to systemically identify adverse events (a harmful and negative outcome that happens due to improper medical care), monitor, investigate, analyze root cause, implement and evaluate its Quality Assurance and Performance Improvement Program (QAPI, a program that is focused on action plan to correct identified quality deficiencies [a deviation in performance resulting in an actual or potential undesirable outcome, or an opportunity for improvement]) related to respiratory care for one of three sampled residents ( Resident 77). Resident 77 ' s change of condition that led to resident ' s death was not investigated, analyzed of the root cause, to determine if the resident ' s death was a result of the facility ' s staff to notify the physician and emergency services, follow oxygen orders, monitor, and document the resident ' s condition, and respond appropriately to severe respiratory distress. As a result of this deficient…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record reviews the facility failed to ensure one of the 18 sampled residents (Resident 48) received his meal tray at the same time with other residents that were sitting in the same table. It was not until 20 minutes later Resident 48 received his meal tray and was eating by himself. This deficient practice violated the rights of Resident 48 to have dignified, equal care and potentially cause emotional distress, loss of appetite, and further affect or damaged to (his, her) health condition. Findings: During an observation on 12/3/24 at 12:15 PM in Activity/Dining Room, Resident 48 was observed sitting in the dining room waiting for the lunch tray while other residents at the same table were eating. During a review of Resident 48 ' s admission Record, indicated Resident 48 was admitted on [DATE] with diagnoses that include but not limited to Gastroesophageal Reflux Disease (GERD- a condition in which the stomach contents leak backward from the stomach into the esophagus (food…

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

Based on observation, interview, and record review, the facility failed to ensure that the call light (a system that alerts the nursing home staff to the needs of a resident) for 2 of two sampled residents (Resident 45 and Resident 46) who were lying in bed was within reach. This deficient practice had the potential to increase the resident ' s risk of falls, heighten the resident ' s anxiety (fear of the unknown) from not being able to easily call for help, and worsen the resident ' s medical condition due to delayed care. Findings: 1. A review of Resident 45 ' s admission Record indicated that the facility admitted the resident on 8/3/2021 and readmitted the resident on 3/7/2024 with diagnoses that included depression (a common mental health condition that can impact a person's thoughts, feelings, behavior, and sense of well-being). A review of Resident 45 ' s Minimum Data Set (MDS - a resident assessment tool), dated 11/4/2024, indicated that the resident ' s cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and senses) was…

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

Based on observation, interview, and record review, the facility did not ensure that one of three sampled residents (Resident 46), was free from the use of physical restraints (anything that inhibits the resident freedom of movement (any change in place or position for the body or any part of the body that the person is physically able to control) and staff convenience. Resident 46 was observed from 11AM to 2:35PM on 12/3/2024 to in a Geri Chair (Geriatric chair a specialized chair with large pad and with wheels designed to assist seniors with limited mobility) with lap table attached to the Geri chair that the resident could not easily remove. This deficient practice had the potential to result in entrapment (an event in which a resident is caught, trapped, or entangled in the space in or about the bed rail), injury and a decline in resident's mobility and/or perform activities of daily living. Findings: During a review of Resident 46 ' s admission Record (Face Sheet), dated 12/4/2024, the face sheet indicated the facility admitted Resident 46 on 12/4/2022, with diagnoses including…

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 one of six sampled residents (Residents 35) preadmission screening and annual resident review (PASARR - a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) assessment screening was complete to determine the facility's ability to provide the special need of the residents. This deficient practice placed the resident at risk of not receiving necessary care and services they need. Findings: During a review of Resident 35's medical diagnosis dated 4/19/22, indicated the resident was admitted to the facility with diagnoses that included depression (a mental illness that changes your mood), anxiety (a feeling of fear, dread, and uneasiness), and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). During a review of Resident 35's Minimum Data Set (MDS--a federally mandated resident assessment tool) dated 5/1/22, indicated that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan as indicated in the facility ' s policy and procedure and physician ' s order for two of two sampled residents (Resident 54 and Resident 16) by failing to: Develop a plan of care for Resident 54 who had a history of thrombocythemia (a disease that caused the body to many too many platelets) and received antiplatelet therapy (medications that prevent blood clots from forming in arteries [tubes that connect to the heart, which distributes oxygen rich blood to the body] and heart by making platelets [disc-like cells that help stop bleeding, form clots, and helps wounds to heal] less sticky. Develop a plan of care for Resident 16 who exhibited the behaviors of agitation, screaming/yelling, and attempted to hit staff. These failures had the potential for Resident 54 not to be monitored for increased bruising or bleeding. In addition, Resident 16 ' s behavior will not be monitored…

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 two sampled residents (Resident 54) was provided care and services for the infected nails by consulting the Dermatology (medicine specialized in treating skin, hair and nails) and Podiatry (medicine specialized in treating foot, ankle, and related structures of the leg) every 2 months and as needed for mycotic (fungal infection that affected the fingernails or toenails) and hypertrophic (nails that are abnormally thicken or misshapen) of the fingernails as ordered by the physician and in accordance with the plan of care. Resident's 54 ' s bilateral fingernails were observed thickened, dry, brittle, and broken after being caught in a blanket. This failure resulted in the resident's nails to fall off and progressive severe infection and pain or discomfort that could lead to hospitalization. Findings: During a review of Resident 54 ' s admission Record, the facility admitted Resident 54 on 3/12/2024 with diagnoses that included…

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 residents who were admitted to the facility with intact skin did not develop a pressure injury to skin and underlying tissue resulting from prolonged pressure on the skin or bony prominences) for one of three sampled residents (Resident 22) who had Stage 3 pressure injury (is a wound where the skin is completely broken, and the damage extends into the deeper layers of tissue beneath it) was not kept clean to prevent recurrent pressure injury. This failure resulted in delayed healing and reopening of the healed pressure injury on the sacrum (a triangular-shaped bone located at the base of the spine, forming the posterior wall of the pelvis). Findings: During a review of Resident 22 ' s admission Record (Face Sheet), the facility admitted Resident 22 on 5/1/2019 and readmitted on [DATE] with diagnoses that included Alzheimer's disease (progressive mental deterioration), and epilepsy (a brain disorder that can cause people 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 ensure residents who have a Gastrostomy Tube (GT, a tube surgically inserted into the stomach or small intestines used to deliver fluids and medications) receive treatment and services to prevent complications such peritonitis (redness and swelling (inflammation) of the lining of the abdomen, and perforation (a small hole) in the peritoneal (lining of the abdominal cavity) and spillage of gastric (acidic fluid in the stomach) contents in the abdominal tissue) for one of three sampled residents (Resident 1) who had GT placed since 2/2024, that the resident pulls out due to confusion. This failure resulted in Resident 1 having seven repeated hospitalizations to the general acute care hospital (GACH) for G-tube dislodgement, had the potential to result in trauma and infection to the g-tube stoma (a small opening in the abdomen), and had the potential to result in Resident 1 experiencing dehydration and malnutrition. Findings: During a review of Resident 1…

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 that Licensed Vocational Nurse (LVN) 6 had the appropriate competencies and skills set to provide nursing care, which included assessing, evaluating, intervening timely and responding to one of three sampled residents (Resident 77) experiencing respiratory distress (trouble breathing often having to work harder to breathe or are not getting enough oxygen) associated with COPD. This failure resulted in the resident condition to decline and resulted in death. Cross reference to F695 and F580 Findings: During a review of Resident 77's admission Record, the facility admitted Resident 77 on [DATE] and readmitted Resident 77 on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD, a chronic lung disease causing difficulty in breathing) with acute exacerbation and pneumonia. During a review of Resident 77's Physician Orders for Life- Sustaining Treatment (POLST, a form that contains written medical orders for healthcare…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to implement appropriate behavior management and interventions to address the resident's behavioral of agitation, yelling, and attempts to hit staff for one of 2 sampled residents (Resident 16) by failing to: Ensure that care and services were person-centered, aligned with the resident's goals, and maximized their dignity, autonomy, privacy, socialization, independence, choice, and safety. Ensure direct care staff did not consistently interact and communicate in ways that supported the resident's mental and psychosocial well-being. This deficiency could have the potential to result in the failure to implement appropriate behavior management interventions to address the resident's behavioral challenges and support their mental and psychosocial well-being. Findings: During a review of Resident 16 ' s admission Record (Face Sheet), dated 12/4/2024, the face sheet indicated the facility admitted Resident 16 on 5/14/2014, and readmitted 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 interviews and records review, the facility failed to ensure one of three residents (Resident 16) was free from unnecessary medications by failing to ensure the resident does not receive Ativan (a medication used to relieve anxiety (severe fear of the unknown) by failing to document the justification for the continued use of Ativan PRN ( as needed) beyond the 14-days limit. These deficiencies have the potential to result in the use of unnecessary medication, that could lead to adverse reaction (undesired outcome of the medication use). Findings: During a review of Resident 16 ' s admission Record (Face Sheet), dated 12/4/2024, indicated the facility admitted Resident 16 on 5/14/2014, and readmitted on [DATE] with diagnoses that included seizures/epilepsy (a brain disorder that can cause people to suddenly become unconscious and have violent, uncontrolled movements of the body), and intellectual disabilities (a developmental disorder that affects a person's ability to learn and function in daily life).…

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 administer medications to two of three sampled residents (Resident 45 and Resident 61) as prescribed by the physician during a medication administration observation that resulted in 7.14 % medication error rate by failing to ensure: 1. Resident 45 was administered vitamin D3 (a vitamin supplement to help prevent bone disorders) oral (given by mouth) tablet 25 micrograms (unit of measurement) via G-tube (a small, flexible tube that's inserted through the stomach wall and into the stomach to deliver nutrition, fluids, and medicine) to 2. Resident 61 was administered multivitamin supplement oral (given by mouth) tablet by mouth. Findings: 1. A review of Resident 45 ' s admission Record indicated that the facility admitted the resident on 8/3/2021 and readmitted the resident on 3/7/2024 with diagnoses that included vitamin D deficiency (a deficiency of not getting enough vitamin D to stay healthy). A review of Resident 45 ' s Minimum Data Set…

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 out of 3 sampled residents (Residents 76) with drinks that accommodated the resident ' s preferences. This deficient practice had the potential to result in decreased fluid intake and can lead to dehydration (not having enough fluid in the body). Findings: During an interview on 12/3/24 at 10:40 AM with Resident 76 regarding food service, Resident 76 stated I have told staff again and again, dietary staff would visit me and I would repeat what I don't want, I don't eat cheese, milk, pork or beef, but I'm still getting that. During an observation on 12/3/24 at 11:55 AM in the kitchen, tray card for Resident 76 indicated No beef. No Pork. No cheese. No milk. During a review of Resident 76 ' s admission Record, Resident 76 was admitted on [DATE] with diagnoses that include spondylosis (a condition in which there is abnormal wear on the cartilage and bones of the neck) and primary osteoarthritis (a progressive disorder of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure the attending physician (Medical Doctor [MD] 1) assessed and evaluated the total program of care for one of three sampled residents (Resident 1) who was diabetic (a person with diagnosis of diabetes) by ensuring the resident ' s blood sugar was monitored [an intervention that is essential for managing diabetes that involves checking blood sugar levels using a device] and Lispro ( a medication that lowers the blood sugar level) to manage Diabetes Mellitus [DM, a chronic disease where a person has high blood sugar levels because the body does not produce insulin (a hormone made by the pancreas- an organ in the body) was not administered while under the physician ' s care in the facility from [DATE] to [DATE] ( a total of 61 days). As a result of this failure, Resident 1 ' s blood sugar was not monitored and did not receive any medication to control Resident 1 ' s blood sugar from [DATE] to [DATE]. On [DATE] at 6:42 PM, Resident 1 was transferred…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the facility ' s pharmacy consultant thoroughly reviewed and reported irregularities to the attending physician and the facility ' s medical director and Director of Nursing (DON) during Medication Regimen Review (MRR-a structured, critical examination of a person's medicines of the residents to ensure they receive the right medications and monitoring needed to optimize the impact of medicines) for one of one sampled residents (Resident 1) who was admitted to the facility from [DATE] to [DATE] (total 2 months), with diagnosis of Diabetes Mellitus Type 2 (DM, a chronic disease where a person has high blood sugar [glucose] levels) and did not receive insulin that was discontinued without clear indication and blood sugar was not monitored. As a result of this failure, Resident 1 ' s blood sugar level was not monitored and did not receive any Lispro (medication to control blood sugar level) from [DATE] to [DATE]. On [DATE] at 6:42 PM, Resident 1 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that outbreaks of communicable disease are identified and reported to the California Department of Public Health (CDPH) and local public health officer, in accordance with the facility ' s policy and procedure on Communicable Diseases – Outbreak. The facility failed to report a Coronavirus 2019 (COVID- 19, an infectious disease) Outbreak in the facility, to the CDPH within 24 hours of occurrence for five (Residents 1, 2, 3, 4, and 5 of eight sampled residents who tested positive for COVID-19. The facility reported to the local health department on 7/16/2024 but did not notify the CDPH. The facility ' s first resident with positive COVID 19 result was Resident 1, As a result, the California Department of Public Health was not aware of the incident and could not conduct a timely on-site investigation to ensure the facility was taking proper precautions to ensure the welfare and safety of the residents and staff during this outbreak. Findings: 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.

Deficiency Text Not Available

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the facility ' s licensed nursing staff met specific annual competencies to skill sets needed to care for a resident ' s respiratory care and services that included respiratory assessments and change in respiratory condition and skills when and how to provide interventions when appropriate for one of two sampled residents (Resident 1). This deficient practice had the potential for Resident 1 to experience a decline in respiratory condition and the potential to delay appropriate treatments and services. Finding: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on [DATE] with diagnoses including acute respiratory failure (difficulty breathing on own) with hypoxia (low levels of oxygen in body tissues), atherosclerotic heart disease (hardening of the blood vessels), and heart failure. During a review of Resident 1 ' s Care Plan dated [DATE], indicated the resident was at risk for SOB with goal…

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 document that one of two sampled residents (Resident 1) were provided respiratory treatment and services in the resident ' s medical records. This deficient practice had the potential for serious negative consequences of patient care and overall compliance with the facility ' s policy with potential to result in medical records containing inaccurate documentation. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 2/14/2024 with diagnoses including acute respiratory failure (difficulty breathing on own) with hypoxia (low levels of oxygen in body tissues), atherosclerotic heart disease (hardening of the blood vessels), and heart failure. During a review of Resident 1 ' s Care Plan dated 2/14/2024, indicated the resident was at risk for SOB with goal of resident not to have signs and symptoms of SOB or discomfort. The care plan Interventions indicated to assess alteration in sputum characteristic and effectiveness of treatment. Resident 1 ' s records 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 observation, interview and record review the facility failed to develop and implement a resident specific comprehensive care plan to (a document that outlines the facility ' s plan to provide personalized care to a resident based on the resident ' s needs) for one of two sampled residents (Resident 1) by failing to: 1. Address appropriate interventions to prevent major injury during recurrent seizure activity (a sudden, uncontrolled burst of electrical activity in the brain that causes uncontrolled movement and loss of consciousness) to one of two sampled residents (Resident 1). 2. Address appropriate interventions for dementia ( a progressive brain disorder that result in memory loss and impairs the thought process). 3. Address appropriate interventions for Resident 1 ' s noncompliance with care and instructions. As a result of these failures Resident fell during seizure activity and resulted in major laceration and bleeding on the head. Findings: A review of Resident 1 ' s GACH 1 record titled History…

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 licensed nursing staff did not administer expired insulin (a medication used to treat high blood sugar) to six out of 10 residents (Resident 5, 6, 7, 8, 12 and 14) whose insulin was found to be expired during the inspection of two of two medication carts (Station 2 Medication Cart 2 and Station 1 Medication Cart 1), and ensure Resident 14 ' s Basaglar (Insulin Glargine) KwikPen (prefilled insulin glargine pen) was administered in accordance with manufacturer ' s specifications of once daily and not as a sliding scale. (Cross Reference F761) These failures resulted in residents (Resident 5, 6, 7, 8, 12 and 14) receiving expired insulin doses and insulin not in accordance with manufacturer ' s specification that could affect the effectiveness of the medication to lower the blood sugar level and the potential to result in serious health complications due to uncontrolled blood sugar levels possibly resulting in hospitalization, coma,…

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 expired and discontinued medications were discarded and disposed of properly according to the facility's policy and procedure. 1. The facility failed to ensure expired insulin (a medication used to treat high blood sugar) was removed and discarded for 10 out of 12 residents (Residents 1, 5, 6, 7, 8, 9, 11, 12, 13, and 14) medications reviewed in two of two inspected medication carts (Station 2 Medication Cart 2 and Station 1 Medication Cart 1). (Cross Reference F760) 2.The facility failed to ensure medication remaining at the facility after one of one resident (Resident 10) was discharged from the facility was removed from active supply, marked discontinued and securely stored until destroyed in accordance with the facility ' s Policy and Procedure (P&P) titled, Discontinued Medications, dated 1/2022. 3. The facility failed to ensure a medication, Eliquis (a blood thinner) prescribed for Resident 15 was disposed of with a witness…

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 post accurate nurse staffing information of actual hours worked by the licensed and unlicensed nursing staff directly responsible for resident care per shift daily and was not posted in a prominent location readily accessible to residents and visitors for viewing in accordance with the facility ' s policy and procedure titled Nursing Department – Staffing, Scheduling and Posting. This deficient practice of posting inaccurate nurse staffing information could mislead the residents and visitors that may affect the quality of nursing care provided to the residents. Findings: A review of the Facility ' s Daily Nursing Staffing Posting , dated 4/8/24 indicated the facility census, projected ppd (per patient day ) for three shifts (day, evening, night) for RN ' s (registered nurse), LVN ' s (licensed vocation nurse), CNA ' s (certified nursing assistant) and RNA ' s (restorative nursing assistant). During an observation, on 4/23/24 at 10:17 a.m., the facility ' s projected daily nursing staffing was observed on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assess the medical need and evaluate the risks of entrapment for the use of full-length bed side rails for seven of 15 sampled residents (Resident 2, 9, 10, 11, 12, 13, and 14). These deficient practices placed the residents at risk for potential accident such as a body part being caught between the rails, falls if a resident attempts to climb over, around, between, or through the rails. Findings: 1. A Review of Resident 2 ' s admission Record indicated the facility admitted the resident on 1/4 /2024, with diagnoses that included but not limited to hemiplegia (unable to move one side of body) and hemiparesis (weakness on one side of body) affecting the left side. A review of Residents 2 ' s History and physical (H&P) dated 1/5/2024, indicated the resident had the capacity to understand and make decisions. A review of Resident 2 ' s Minimum data Set (MDS- a standardized assessment tool that measures health status in nursing home 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 ensure a resident was free from physical restraints, when Certified Nurse Assistant (CNA) 1 placed both full length side rails up of the bed to prevent one of three sampled residents (Resident 2) from getting out of bed, without a physician ' s order and ongoing assessments, in accordance with the facility policy and procedure on Bed Rails and Restraints. This deficient practice had the potential to place Resident 2 for accidents, injury and decline in physical functioning due to the use of bed side rails on both sides of the bed, without physician orders and ongoing assessment. In addition, this deficient practice had the potential to cause depression, feelings of imprisonment and loss of dignity and respect. Findings: A Review of Resident 2 ' s admission Record indicated the facility admitted the resident on 1/4/2024, with diagnoses that included but not limited to hemiplegia (unable to move one side of body) and hemiparesis (weakness 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 observation, interview, and record review, the facility failed to ensure that a system was in place to provide a safe resident environment for residents who smoke and for residents who do not smoke. The facility failed to identify smoking hazards for (8) eight of (8) sampled residents (Residents 1, 2, 3, 4, 5, and 6) who uses a non-smoking designated area at the facility ' s courtyard patio to smoke and failed to ensure residents (Residents 7 and 8) who do not smoke and was on continuous oxygen use were kept safe, comfortable and free from the hazards of second hand smoke, as indicated in the resident ' s written plans of care and the facility ' s policy and procedure on Smoking. These deficient practices had the potential for residents to acquire unexpected burns, fire hazard and /or injuries caused by unsafe smoking and exposed non-smoking residents and visitors to secondhand smoke. Findings: During an interview on [DATE] at 11:04 AM, the facility ' s Activity Director (AD) was interviewed regarding…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop resident-centered care plan for one of six sampled residents (Resident 6). Resident 6 did not have a care plan for smoking. This deficient practice had the potential for care and services to be delayed based on the specific needs of the resident. Findings: During a re view of Residents 1, 2, 3, 4, 5, and 6 medical records, the following information were obtained: 1. A review of Resident 1 ' s admission Record indicated the resident was initially admitted to the facility on [DATE], with the diagnoses including unspecified psychosis (a mental disorder characterized by a disconnection from reality), depression (constant feeling of sadness), and cardiomyopathy (diseases of the heart muscle, where the walls of the heart chambers have become stretched, thickened, or stiff. This affects the heart's ability to pump blood around the body). A review of Resident 1 ' s History and Physical dated 6/06/2023, indicated the resident had mild dementia (impaired…

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 accommodate the need for three of four sampled residents (Resident 59 and 38) by ensuring the resident's call light device (an alerting device for nurses or other nursing personnel to assist a resident when in need) was within reach ((Resident 59 and 38). As a result of this deficient practice the residents are at risk of not receiving the care and needed especially during an emergency and a potential decline in the resident's activities for daily living, self-esteem, and self-worth. Findings: 1. A review of Resident 59's Record of Admission, dated 10/19/22, the record indicated, Resident 59 was admitted to the facility on [DATE] with diagnoses that included Cerebrovascular Accident (CVA-a stroke of an interruption of blood flow to the brain) with left hemiparesis (weakness or the inability to move on one side of the body), Type 2 diabetes mellitus (DM2 - condition that results in too much sugar circulating in the blood), hypertension…

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 develop and implement a comprehensive person-centered care plan for the use of psychotropic medications (medications that affects mood and behavior) for four of four sample residents (Resident 25, 63, 40 and 41). The facility failed to: 1. For Resident 25 a plan of care was not developed while receiving psychotropic (medications that affects mood and behavior) medications. 2- For Residents 63 and 40 a plan ofa care was not developed for smoking and saafety. 3. For Resident 41 a plan of care was not developed to address weight loss. These deficient practices put the residents at risk for not receiving necessary care and services to achieve their highest potential. Findings: 1. During a review of Resident 25's Record of admission indicated the facility initially admitted Resident 25 on 3/23/22 and readmitted the resident on 9/29/23 with diagnoses that included heart failure (a condition that develops when the heart does not pump enough blood…

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 its residents with limited range of motion (ROM - movement of the joints) receive appropriate treatment and services to increase, prevent, or maintain the ROM mobility for three of four residents (Resident 59, 38 and 48) with the physician's orders for Restorative Nursing Assistant (RNA) assisted exercises. 1. Residents 59 did not receive RNA assisted exercises from 11/1/23 to 11/24/23 (a total of 24 days), 2. Resident 38 was not provided RNA assisted ROM exercises from 11/1/2023 to 11/24/2023 as (a total of 24 days) ordered by the physician. 3. Resident 48 was not provided RNA assisted ROM and AAROM exercises from 11/1/2023 to 11/24/2023 as (a total of 24 days) ordered by the physician. These deficient practices place Resident 59, 39 and 48 at risk for decline in physical function, mobility, and contractures (a condition that results in muscles, tendons, joints, or other tissues to tighten or shorten causing a deformity) pain, and permanent…

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 of two sampled residents (Resident 63 and Resident 40) were assessed to safely smoke in the facility. 1. Resident 63 did not have a smoking assessment completed. 2. Resident 40 did not have a smoking assessment completed. This deficient practice had a potential to cause a fire hazard and /or injuries caused by unsafe smoking. Findings: A review of Resident 63's admission Record indicated the resident was initially admitted to the facility on [DATE] with the diagnosis of chronic obstructive pulmonary disease (lung disease that blocks airflow from the lungs) and congestive heart failure (weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs). A review of Resident 63's Minimum Data Set (MDS - a standardize assessment and care screening tool) dated 10/19/2022 indicated that the resident had intact cognition (the ability or mental action or process of acquiring knowledge and understanding). 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 the pharmacy consultant accurately identify and report irregularities to the attending physician and facility's medical director and the Director of Nursing (DON) during the drug regimen review for 5 of 5 sampled residents (Residents 30, 44,18 ,59 and 25). The pharmacy consultant failed to identify the irregularities in the following residents receiving psychotropic (medications that affects mood and behavior) medications. 1a. Resident 30 received Seroquel (an antidepressant or medication used to treat depression [a feeling of severe sadness and hopelessness]) for mood/agitation as ordered by the physician. 2. Resident 44 received Remeron (antidepressant) for depression, manifested by poor appetite and Klonopin for anxiety (feeling of severe fear of the unknown) was not monitored for frequency of occurrence or tally (count) by hashmark every shift and its side effects as ordered by the physician. 3. For Resident 18, received Seroquel had no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to monitor the presence of the resident's target behaviors to justify the continued use of an antipsychotic medication (a medication used to treat psychosis or mental illness) and its adverse effects (side effects) daily, as indicated in the facility's policy and procedure on Psychotherapeutic Drug Management and Guideline for Psychotherapeutic Medications, for four of four sampled residents (Resident 30, 44, 25 and 18). 1. Resident 30 was taking Seroquel ( a medication used to treat mood and agitation). The target behavior manifested by mood and agitation and its corresponding side effects were not monitored November and December 2023, as indicated in the physician's orders. Resident 30 received Seroquel (class of drug belongs to antipsychotic) 75 mg instead of 25 mg on 11/8/23,11/9/23,11/10/23,11/11/23,11/12/23, 11/13/23 (6 days extra dose of 50 mg of Seroquel) Resident 30 received Seroquel 50 mg instead of 25 mg on 11/14/23 to 12/2/2023 (50 doses).…

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 properly store foods in the refrigerator. These deficient practices had the potential to result in residents being exposed to food borne illnesses. Findings: During an observation of the kitchen during the initial kitchen tour on 12/5/2023 at 8:35 AM with the Dietary Supervisor (DS), the dry storage area was observed. A sticky brown substance the size of a silver dollar coin was observed on a container lid of sugar. During an interview on 12/5/23 at 8:36 AM with the dietary supervisor (DS), DS stated the sugar container lid should be clean and free of debris, and that a sticky substance could attract roaches and would contaminate the food. During a concurrent observation and interview of the kitchen during the initial kitchen tour on 12/5/2023 at 8:48 AM with the DS, refrigerator 1 was observed to have 35 prepared white liquid in cups without labels or dates. The DS stated the cups with white liquid was milk, and should have been labeled with what the contents was, and the date the milk was prepared. The DS…

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, monitor, and evaluate identified Quality Assurance and Performance Improvement Program (QAPI, a program that is focused on action plan to correct identified quality deficiencies (a deviation in performance resulting in an actual or potential undesirable outcome, or an opportunity for improvement) relating to residents receiving psychotropic (a drug that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) and with skin breakdown. The facility failed to: 1. Documented evidence the QAPI program implemented a plan to ensure the drug regimen irregularities were identified accurately and reported to the physician, the medical director and Director of Nursing (DON) from the month of November 2023 to December 2023 by the pharmacy consultant. 2. Document evidence that the QAPI plan had a specific staff to oversight the implementation of the plan to assess, monitor and prevent further repeat…

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 implement the facility's policy and procedure on infection control to prevent spread of infection by ensuring 1. nasal cannula (NC) tubing (a device used to deliver supplemental oxygen placed directly on a resident's nostrils) and humidifier is changed weekly in accordance with the facility's policy and procedure for Oxygen Administration for one of 3 sampled residents (Resident 30). 2.the nasal cannula (NC-a device used to deliver supplemental oxygen to people) tubing was not touch the floor for two of 10 sampled residents (Resident 68 and Resident 170)' This deficient practice has a potential for 1.Resident 30 and other potential residents receiving oxygen therapy to develop an infection associated. 2.Resident 68 and 170 to use contaminated or soiled NC tubing and result in the infection (a process when a microorganism, such as bacteria, fungi, or a virus, enters a person's body and causes harm) and a widespread infection in the facility.…

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 education regarding the risks and benefits and side effects (undesired effect) of influenza or flu vaccine (a medication administered via injection to prevent particular kinds of flu viruses that causes flu [a contagious respiratory illness]) prior to the administration of the flu vaccine for four of five sampled residents (Resident 10, Resident 45, Resident 46, and Resident 59). This deficient practice violated the resident or responsible party's rights to make an informed decision. Findings: 1.During a review of Resident 10's Record of admission indicated the facility admitted Resident 10 on 3/4/2009 with diagnoses that included hypertension (high blood pressure) and diabetes mellitus (a diseases that result in too much sugar in the blood). During a review of Resident 10's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 9/4/23, indicated Resident 10 had moderately impaired memory and cognition (ability to think…

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 assess and provide on-going activities, based on resident's preferences, interests and support the physical, mental and psychosocial (mental and emotional) well-being of two of six sampled residents (Resident 6 and Resident 59). This deficient practice had the potential for the resident's quality of life to decline and not to meet the residents highest practicable psychosocial well-being of the residents. Findings: 1. A review of Resident 59's Record of Admission, dated 10/19/22, the record indicated, Resident 59 was admitted to the facility on [DATE] with diagnoses that included Cerebrovascular Accident (CVA, a stroke or an interruption of blood flow to the brain) with left hemiparesis (weakness or the inability to move on one side of the body, dementia [the loss of cognitive functioning (thinking, remembering, and reasoning) to such an extent that it interferes with a person's daily life and activities. A review of Resident 59's Minimum…

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 assess, monitor, and intervene to prevent skin breakdown for one of four sampled resident (Resident 6). Resident 6 was observed with an arterial wound (a wound due to lack or decreased blood flow of the arteries on the foot) on the right second toe with dry scab covering the wound that was not previously identified by the facility. A bed cradle (a frame installed at the foot of the bed to keep sheets/blankets off legs/feet) was not used for Resident 6 as ordered by the physician for wound prevention and management. As a result of this deficient practice Resident 6 did not receive wound treatment and monitoring that could result in worsening and development of new skin breakdown. Findings: A review of Resident 6's Record of Admission, dated 12/30/20, indicated, Resident 6 was admitted to the facility on [DATE] with diagnoses that included dementia (the loss of cognitive [thinking, remembering, and reasoning] functioning to such an extent…

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 residents received the correct amount of gastrostomy tube (GT - an opening to the stomach from the abdominal wall made surgically for the introduction of food) feeding formula for one of three (3) sampled residents (Resident 30). This deficient practice placed the resident at risk for weight control problems and hydration problems (a harmful reduction or increase in the amount of water in the body). Findings: A review of Resident 30's Face Sheet (admission record) indicated the resident was admitted to facility on 3/30/2023 with medical diagnoses of Parkinson's Disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), dysphagia (difficulty swallowing), and quadriplegia (paralysis of the legs and arms). A review of Resident 30's initial History and Physical dated 03/31/2023 indicated Resident 30 did not have capacity to make decisions. A review of Resident 30's Minimum Data Set (MDS, a standardized resident assessment and care screening 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 observation, interview, and record review, the facility failed to medically related services by failed to coordinate the care with the hospice agency (an agency in charge end of life concern) for one of three sampled residents (Resident 23) who was under hospice care, to ensure the resident received services to renew the identification card Medi-Cal card (a government funded medical insurance). This deficient practice had the potential to negatively affect the resident's psychosocial well-being and delay the delivery of care services to Resident 23. Findings: During a review of Resident 23's admission record, it indicated Resident 23 was admitted on [DATE] with diagnoses that included unspecified heart failure (a disorder characterized by the inability of the heart to pump blood at an adequate volume to meet tissue metabolic requirements), unspecified atrial fibrillation (an irregular and often very rapid heart rhythm), extrapyramidal (impaired motor control) and essential hypertension (high blood…

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, record review, the facility failed to ensure Certified Nurse Assistant (CNA) 5 received training on abuse prevention and reporting prior to performing resident care at the facility. This failure had the potential to result in failure to identify or report abuse and result in emotional distress to one of three sampled residents (Resident 1) as indicated in Resident 1 ' s care plan and in accordance with the facility ' s policy on Orientation Program for Newly Hired Employees, Transfers, Volunteers. Findings: A review of Resident 1 ' s Record of admission indicated the resident was initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses of epilepsy (a neurological disorder in which a person has two or more unprovoked seizures that occur more than 24 hours apart) and myocardial Infarction (partial blockage of one of the coronary arteries, causing reduced flow of oxygen-rich blood to the heart muscle). A review of Resident 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 observation, interview, and record review, the facility failed to maintain a safe, sanitary environment to help prevent the spread Coronavirus 2019 (COVID-19, an illness caused by a virus that can spread from person to person) and other infectious diseases for seven (7) of seven (7) sampled residents (Residents 4, 5, 6,7,8,9 and 10) in accordance with the facility ' s policy and procedure by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 4 changed isolation gown before and after performing nasal rapid COVID-19 (used to detect antigens of the SARS-CoV-2 virus in individuals suspected of having COVID-19) for Resident 4 and 5. 2. Ensure Certified Nurse Assistant (CNA) 2 performed hand hygiene (a way of cleaning the hands, which can prevent the spread of germs) before exiting Resident 7 ' s room and entering Resident 8 ' s room in the COVID-19 Zone (residents who positive for COVID-19). 2b. Ensure that CNA 2 doff (remove) personal protective equipment (PPE, equipment worn to minimize exposure to 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 The facility (Facility 1) failed to ensure that sufficient preparation, orientation, and discharge planning were provided for one of one resident (Resident 2) prior to discharge to Facility 2, by failing to: 1. Explain and discuss to Resident 2 or resident ' s representative the reason why the resident was being discharged to another facility (Facility 2) and could not remain at Facility 1. 2. Document the orientation and preparation of Resident 2 ' s discharge plans to Facility 2. 3. Ensure Resident 2 ' s discharge documentation and notification contained a valid basis for discharge. 4. Ensure that a reasonable advance notice was provided to Resident 2 and resident ' s representative prior to discharge. 5. Ensure Resident 2 was transferred to an appropriate locked facility. As a result, Resident 2 was discharged from the facility without receiving discharge planning and being informed of their rights prior to discharge from the facility. A review of Resident 2 ' s admission Record indicated the resident was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to put measures in place to ensure safety and supervise residents who had diagnoses of mental illness and were deemed at risk for elopement (leaving a facility without notice) to properly provide supervision to prevent episodes of elopement. These deficient practices resulted in 1 out of 2 sampled residents (Resident 1) leaving the facility unsupervised on 8/16/23 and placed the residents at risk for serious injuries, death, and had the potential for residents to elope from the facility. Findings: A review of Resident 1 ' s admission Record indicated the resident was initially admitted to the facility on [DATE] with the diagnosis of dementia (the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), essential hypertension (high blood pressure that is not due to another medical condition). A review of Resident 1 ' s History and Physical (H and P) dated 4/20/23 indicated the resident 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.