Imperial Crest Health Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to conduct monthly Medication Regimen Review (a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) of one of five sampled residents' (Resident 50) medical record. This failure had the potential for the facility to not identify irregularities, significant risks, or actual or potential adverse consequences which may result from or be associated with the resident's current medication. This failure had the potential to affect in maintaining the resident's highest practicable level of physical, mental and psychosocial wellbeing.Findings: During a review of Resident 50's admission Record, the admission Record indicated Resident 50 was admitted to the facility on [DATE] with diagnoses including epilepsy (a brain condition that causes a person to have repeated seizures [abnormal electrical activity in the brain]),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide a safe and sanitary environment for three of three sampled residents (Residents 103, 41, and 54) by failing to ensure:1). Humidifier bottles (devices used with oxygen to add moisture to the oxygen being delivered, enhancing comfort and effectiveness during oxygen therapy) and oxygen tubings were dated when changed. 2). Resident 54, who had a tracheostomy (a surgical opening in the neck for an airway) tube and with mouth open, had a room free of flies.These failures had the potential to cause cross contamination and placed Residents 103, 41, and 54 at risk for infections.Findings: During an observation and interview on 5/19/2026 at 10:01 a.m., in Residents 103 and 41's room, with Registered Nurse Supervisor (RNS) 2, RNS 2 stated the residents' humidifier bottles and tubing were not dated. RNS 2 stated if the humidifier bottle and tubing were not dated, the facility staff would not know when to change them. RNS 2 stated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one out of three sampled residents (Resident 4) an accusation of sexual abuse was reported within two hours. This deficient practice of not reporting the accusation of sexual abuse by Resident 4 had the potential to cause psychosocial harm (factors that could harm someone ' s mental health). Findings: During a review of Resident 4 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 4 diagnoses dementia (a progressive state of decline in mental abilities), depressive disorder (a mental condition characterized by persistent feelings of sadness, loss of interest, and other symptoms that can significantly impair daily functioning), and transient cerebral ischemic attack (a lack of blood flow to the brain). During a review of Resident 4 ' s History and Physical (H&P), dated 6/4/2024, the H&P indicated Resident 4 did not have the capacity to understand and make…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, facility licensed staff failed to ensure the Medical Director (a licensed physician who oversees and manages the medical aspects of a healthcare organization or facility) was notified after licensed staff could not reach the primary physician for one out of three sampled residents (Resident 1). This deficient practice resulted in facility staff had to call 911 to transport the resident to the General Acute Care Hospital (GACH) . 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 chronic respiratory failure (COPD, a chronic lung disease causing difficulty in breathing), obstructive uropathy (refers to any condition where the normal flow of urine is blocked or impeded within the urinary tract), and anemia (a condition where the body doesn ' t have enough healthy red blood cells). During a review of Resident 1 ' s History and Physical (H&P), dated 4/22/2025, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1). Ensure expired one opened bottle of vitamin B1 (one of the B vitamins) medication was not kept in the medication cart 1. This deficient practice had the potential to result in administering expired medication to the residents with orders. 2). Label with an opened date, the Ipratropium with Albuterol Solution (a combined inhalation solution to treat and prevent shortness of breath) pouch in medication cart 1 for Resident 33, that had a pharmacy fill date of 7/3/2024. 3). Ensure expired one pouch of Ipratropium with Albuterol Solution for Resident 83 was not kept in medication cart 1. These failures had the potential for the affected residents to receive expired medications. These failures placed the medications at risk of bacterial growth and less potent, which can fail to treat shortness of breath and chest congestion for Resident 33 and Resident 83's shortness of breath or wheezing, when needed. Findings: 1). During a concurrent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the juice connectors for the apple, grape, and pineapple juice was free of sticky residue. This deficient practice had the potential to result in cross contamination (movement of bacteria from one place to another) in the kitchen. Findings: During a concurrent observation and interview on 4/2/2025 at 9:20 a.m. with the Dietary Supervisor (DS), the connectors for the apple, grape, and pineapple juice was observed with a sticky substance. The DS stated the connectors contained dust and sticky residue that can cause cross contamination resulting in infection. During a review of the facility's policy and procedure (P&P) titled, Food Receiving and Storage, dated 11/2022, the P&P indicated food services staff should maintain clean food storage areas. Non-refrigerated foods should be kept clean.

Based on observation and interview, the facility failed to ensure three dumpsters (trash container) were kept closed. This deficient practice had the potential to result in rodents and insects being attracted to the facility and cause contaminations and infections. Findings: During a concurrent observation and interview on 4/1/2025 at 8:41 a.m. with the [NAME] in the parking lot, three dumpsters were noted with the lids off. The [NAME] stated the dumpsters should be closed to prevent possible contamination. The [NAME] stated if there were food inside it could attract animals. During a review of the facility's policy and procedure (P&P) titled, Food-Related Garbage and Refuse Disposal, dated 10/2017, the P&P indicated dumpsters should be kept closed and free of surrounding litter. Dumpsters must be kept covered when stored or not in continuous use.

Based on observation, interview, and record review, the facility failed to ensure one of two residents (Resident 52) had a call light (call bell) device within easy reach. This deficient practice had the potential to result in the resident being unable to alert health care workers for assistance for activities of daily living and care needs. Findings: During a review of Resident 52's admission Record (Face Sheet), indicated the facility re-admitted the resident on 3/29/2025 with diagnoses including functional quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury) and unspecified dementia (a progressive state of decline in mental abilities). During a review of the Minimum Data Set (MDS - (a resident assessment tool), dated 2/7/2025 indicated Resident 52 had functional limitation in range of motion in both upper extremities. During a review of Resident 52's care plan report, initiated on 3/31/2025 indicated the following goals: assistance in calling for help, in being kept clean, dry, and odor free by placing the call light device…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 use of an anti-psychotic (a class of drug used to treat mental health conditions) medication was accurately documented in the Minimum Data Set ([MDS] a resident assessment tool) for one of eight sampled residents (Resident 38). This deficient practice resulted in Resident 38's inaccurate medical condition submitted to the Centers for Medicare/Medicaid Services (CMS). Findings: During a review of Resident 38's admission Record, the admission Record indicated Resident 38 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 38's diagnoses included bipolar disorder (mood swings that range from the lows of depression to elevated periods of emotional highs), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and heart failure (a heart disorder which causes the heart to not pump the blood efficiently). During a review of Resident 38's History and Physical (H&P), dated 1/10/2025,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 weekly weight order was conducted weekly for one of 4 sampled residents (Resident 149). This deficient practice had the potential to result in the facility not knowing the resident had excessive weight loss or weight gain which could lead to delay in providing interventions needed for the resident. Findings: During a review of Resident 149's admission Record, the admission Record indicated Resident 149 was admitted on [DATE] with diagnoses including dysphagia (difficulty swallowing), type 2 diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing), schizophrenia (a mental illness that is characterized by disturbances in thought) and hyperlipidemia (a condition characterized by elevated levels of fats in the blood). During a review of Resident 149's history and physical (H&P), dated 3/14/2025, the H&P indicated Resident 149 did not have the capacity to make decisions . During a review of Resident 149'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 place the low air loss mattress (LALM- a pressure relieving mattress for the management of pressure ulcers [localized damage to the skin and/or underlying tissue usually over a bony prominence]) at the proper setting, according to the manufacturer's recommendation, for one of five sampled residents (Resident 58). This deficient practice had the potential to cause discomfort, new pressure injuries, poor wound healing and deterioration of the current pressure ulcers for Resident 58. Findings: During a review of Resident 58's admission Record, the admission Record indicated Resident 58 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 58's diagnoses included pressure ulcer of the sacrum (a large, triangular bone at the base of the spine), left and right buttock, and cellulitis (a skin infection that causes swelling and redness). During a review of Resident 58's History and Physical (H&P) dated 12/14/2024, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents on tube feeding received treatment and care in accordance with professional standards of practice, by failing to: 1. Ensure the head part of Geri-chair (a fully reclining chair designed for individuals with limited mobility, offering multiple positions for comfort and support) was elevated while one of three residents, (Resident 10), was lying in and received gastrostomy tube ([GT] - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) feedings. This deficient practice placed the resident at risk of aspiration (inhalation of foreign materials) that can lead to pneumonia (lung infection), hospitalization and death. Findings: During a review of Resident 10's admission Record, the admission Record indicated, Resident 10 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 10's diagnoses included anemia…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 one sampled resident (Resident 42) was evaluated by a physician every 60 days and document his visit in resident's clinical records. This deficient practice had the potential for Resident 42's current medical condition not timely assessed by a physician that can lead to delay in necessary care and treatment. Findings: During a review of Resident 42's admission Record, the admission Record indicated, Resident 42 was admitted to the facility on [DATE]. Resident 42's diagnoses included liver cirrhosis (a condition in which the liver is scarred and permanently damaged), hypertension ([HTN] - high blood pressure), and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 42's Minimum Data Set ([MDS] - a resident assessment tool), dated 3/20/2025, the MDS indicated, Resident 42's cognitive (ability to think and reason) skills for daily decision making was consistent and reasonable. 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 ensure one of one sampled resident (Resident 42) was evaluated by a physician every 60 days and document his visit in resident's clinical records. This deficient practice had the potential for Resident 42's current medical condition not timely assessed by a physician that can lead to delay in necessary care and treatment. Findings: During a review of Resident 42's admission Record, the admission Record indicated, Resident 42 was admitted to the facility on [DATE]. Resident 42's diagnoses included liver cirrhosis (a condition in which the liver is scarred and permanently damaged), hypertension ([HTN] - high blood pressure), and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 42's Minimum Data Set ([MDS] - a resident assessment tool), dated [DATE], the MDS indicated, Resident 42's cognitive (ability to think and reason) skills for daily decision making was consistent and reasonable. 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 observation, interview and record review, the facility failed to administer accurate amount of medication, to one of 29 residents (Resident 10), according to the physician's order. This failure had the potential for the medication to provide ineffective effect to the resident. Findings: During a review of Resident 10's admission Record, the admission Record indicated, Resident 10 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 10's diagnoses included anemia (a condition where the body does not have enough healthy red blood cells), gastrostomy ([GT] - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and chronic obstructive pulmonary disease ([COPD] - a chronic lung disease causing difficulty in breathing). During a review of Resident 10's History and Physical (H&P), dated 2/18/2025, the H&P indicated, Resident 10 did not have the capacity to understand and make decisions.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure, one of eight sampled residents' (Resident 16), Complete Blood Count ([CBC]- a blood test that measures the number and type of cells in your blood) and Albumin (a blood test to check the level of protein in the blood) orders were implemented, as ordered by the physician on 12/11/2024. This deficient practice resulted in inadequate monitoring of Resident 16's health status. Findings: During a review of Resident 16's admission Record, the admission Record indicated Resident 16 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 16's diagnoses included diabetes (DM-a disorder characterized by difficulty in blood sugar control, dysphagia (difficulty swallowing) and quadriplegia (the loss of muscle function in all limbs). During a review of Resident 16's History and Physical (H&P), dated 1/9/2025, the H&P indicated Resident 16 did not have the capacity to understand and make decisions. During a review of Resident 16'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 the foley catheter (a thin, flexible tube inserted into the bladder to drain urine) removal for one of one sampled resident (Resident 85) was documented, according to the facility's policy and procedure (P&P). This deficient practice had the potential to result in the lack of communication between staff and a delay in the provision of care or interventions for Resident 85. Findings: During a review of Resident 58's admission Record, the admission Record indicated Resident 58 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 58's diagnoses included pressure ulcer (localized damage to the skin and/or underlying tissue usually over a bony prominence) of the sacrum (a large, triangular bone at the base of the spine), left and right buttock, and cellulitis (a skin infection that causes swelling and redness). During a review of Resident 58's History and Physical (H&P), dated 12/14/2024, the H&P indicated Resident 58…

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

Based on observation, interview, and record review, the facility failed to follow appropriate infection control practices for one of two residents (Resident 52) who was on enhanced barrier precautions [EBP, an infection control intervention designed to reduce the transmission of multidrug-resistant organisms (MDROs)]. This deficient practice had the potential to result in spread of infectious disease. Findings: During an observation on 4/1/2025 at 10:31 a.m., The Director of Nursing (DON) and Licensed Vocational Nurse (LVN) 4 entered Resident 52's room from the hallway, and were observed not performing hand hygiene before entering the resident's room, before touching the resident's linen, after assisting the resident, and before leaving the resident's room. During an interview on 4/1/2025 at 10:39 a.m. with the DON, the DON stated hand hygiene should be performed before touching the residents. During an interview on 4/1/2025 at 12:05 p.m., at the nurse's station, Licensed Vocational Nurse (LVN) 4 stated staff were to wash hands between each resident especially when transitioning…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an allegation of abuse to the California Department of Public Health (CDPH), within two hours, when one out of three residents, Resident 1, alleged a Registered Nurse (RN) hit her on the right side of the face on 3/1/2025. This deficient practice had the potential to place Resident 1 at risk for further abuse and resulted in a delay in investigation of alleged abuse. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 ' s diagnoses included muscle weakness and anxiety disorder (mental health condition characterized by excessive, persistent, and often irrational worry, fear, and unease that can interfere with daily life). During a review of Resident 1 ' s History and Physical (H&P) dated 2/19/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1 ' s admission Reassessment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents received treatment and care in accordance with professional standards of practice, by failing to ensure: 1). Oral care was provided for one of three sampled residents, (Resident 3). 2). Restorative Nurse Assistants (RNAs) staff were assigned to provide exercises per resident-centered care plan to two out of three residents, (Residents 2 and 3). This failure had the potential to cause tooth decay and oral infections. This failure had the potential for all residents with ROM plan of care/ orders to not receive the services and could affect in maintaining the highest practicable physical, mental, and psychosocial well-being of the affected residents. Findings: 1). During a review of Resident 3 ' s admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE], with diagnoses including hemiplegia (severe or complete loss of strength) and hemiparesis (mild loss of strength) following cerebral…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure safe storage of two tube feeding formula bottles for one of three sampled residents (Resident 3.) This deficient practice had the potential for other residents to access and drink the formula and cause adverse reactions like diarrhea or upset stomach. Findings: During a review of Resident 3 ' s admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE], with diagnoses including hemiplegia (severe or complete loss of strength) and hemiparesis (mild loss of strength) following cerebral infarction (lack of oxygen due to disruption in blood flow in an area of the brain) affecting left non-dominant side and adult failure to thrive (a state of overall decline that may be caused by chronic diseases and functional impairments). During a reviewof Resident 3 ' s Minimum Data Set ([MDS], a standardized assessment and care screening tool), dated 11/15/24, the MDS indicated Resident 3 was able 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 readmit Resident 1 to the facility after being cleared by the general acute care hospital (GACH) to return to the facility. This deficient practice of not allowing Resident 1 to be readmitted to the facility had the potential to displace the resident. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included chronic obstructive pulmonary disease ([COPD] a chronic lung disease causing difficulty in breathing), encephalopathy (a brain disorder or disease that affects the brain's function), and heart failure (a condition where the heart is unable to pump enough blood to meet the body's needs resulting in inadequate oxygen delivery to organs and tissues). During a review of Resident 1's History and Physical (H&P), dated [DATE], the H&P indicated, Resident 1 had the capacity to make medical decisions. 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 implement its policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigating, which indicated the facility should report allegations of abuse immediately to the State licensing/certification agency responsible for surveying/licensing the facility (California Department of Public Health [CDPH]). This failure delayed the investigation by the CDPH. 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 respiratory failure (a serious condition that occurs when the lungs are unable to provide enough oxygen to the blood or remove enough carbon dioxide), unspecified (unknown), unspecified whether with hypoxia (low levels of oxygen in the body ' s tissues) or hypercapnia (too much carbon dioxide in the blood). During a review of Resident 1 ' s History and Physical (H&P), dated 9/11/2024, 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 interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigating, for one of 3 sampled residents (Resident 1), which indicated, all reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property, are thoroughly investigated by facility management. This failure had the potential for Resident 1 to receive continued abuse and placed Resident 1 at risk for further physical and psychosocial harm. Findings: During a review of Resident 1 ' s admission Record, dated 9/20/2024, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including respiratory failure (a serious condition that occurs when the lungs are unable to provide enough oxygen to the blood or remove enough carbon dioxide), unspecified (unknown), unspecified whether with hypoxia (low levels of oxygen in the body ' 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 provide care in a manner that maintained or enhanced resident's dignity and respect in full recognition of his individuality for one of three sampled residents (Resident 1) when LVN 1 verbally threatened Resident 1. This deficient practice resulted in Resident 1 feeling upset and had the potential to negatively affect his psychosocial well-being. Findings: A review of Resident 1's admission Record, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of nontraumatic intracerebral hemorrhage (bleeding in the brain caused by the rupture of a damaged blood vessel in the head), type 2 diabetes mellitus ([DM] a chronic condition that affects the way the body processes blood sugar) and epilepsy (a brain condition that causes recurring seizures). A review of Resident 1's History and Physical (H&P), dated 5/1/2024, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set ([MDS], an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 undressed, cleaned wounds for the two of 2 residents (Residents 1 and 2), did not touch the bed's mattress after the wound care was done. This deficient practice placed the residents ' wounds at increased risk for wound infection. Findings: a). A review of Resident 1 ' s admission record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE], with a diagnosis of muscle weakness (physical weakness or a lack of energy), type 2 diabetes mellitus (abnormal sugar levels), and acute osteomyelitis, left ankle and foot (bacterial or fungal infection of the bones, leading to inflammation and potential complication). A review of Resident 1 ' s history and physical (H&P) dated 4/12/2024 indicated Resident 1 was awake, not alert, unresponsive, nonverbal. A review of Resident 1 ' s minimum data set ([MDS] a standardized care assessment and care screening tool), dated 1/24/2024, indicated 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.

Based on observation, interview, and record review the facility failed to: 1. Ensure laundry rubber gloves were properly cleaned and stored after use. This deficient practice of not having the laundry rubber gloves cleaned stored placed the Residents at risk for the spread of infection. 2. Ensure there is a comprehensive water management program in place to prevent Legionella (a bacteria that causes Legionnaires [a severe form of pneumonia - lung infection/inflammation usually caused by infection] and other waterborne pathogens (any organisms or agent that can cause disease) to grow and spread in the facility. This deficient practice had the potential for residents of the facility to contract a waterborne pathogen including Legionella. Findings: a. During an observation on 4/5/2024 at 10:20 a.m. there were blue rubber gloves placed on the sink where the staff washes their hands. During a concurrent observation and interview on 4/5/2024 at 10:21 a.m. with Maintenance Supervisor (MS) 1. MS 1 stated the blue rubber gloves should not be hanging on the sink. MS 1 stated the process is 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 b. During a review of Resident 81's admission Record (Face Sheet), the admission Record indicated Resident 81 was admitted to the facility on [DATE] with diagnoses that included spinal stenosis (narrowing of the spinal column that causes pressure on the spinal cord) motor system that manifest as rigidity and tremors of the body), hydrocephalus (a condition in which excess cerebrospinal fluid buildup), and ataxia (a lack of balance coordination and trouble walking). During a review of Resident 81's History and Physical (H&P), dated 1/19/2024, the H&P indicated, Resident 81 has the capacity for medical decision making. During a review of Resident 81's Minimum Data set ([MDS] a standardized care screening and assessment tool), dated 1/24/2024, the MDS indicated, Resident 81's cognition (ability to learn reason, remember, understand, and make decisions) was oriented and able to recall information. The MDS indicated, Resident 81 activities of daily living ([ADL] activities related to personal care) Resident 81…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure resident 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 25). This deficient practice violated the residents' right to make an informed decision regarding the use of psychoactive medications. Findings: During a review of Resident 25's admission Record, the admission Record indicated Resident 25 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 25's diagnoses included major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy), schizophrenia (a mental disorder that affects a person's ability to think, feel and behave clearly), and anxiety disorder (persistent and excessive worry that interferes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 revise a care plan for one out five Residents (Resident 11). This deficient practice of not having a revised care plan placed Resident 11 at risk of not having the appropriate interventions for a contracted (a tightening of the muscles that causes the joint to shorten and become stiff) neck. Findings: During a review of Resident 11's admission Record (Face Sheet), the admission Record indicated Resident 11 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included contractures (a condition of shortening and hardening of muscles, tendons, and rigidity of joints), chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing related problems), and encephalopathy (damage or disease that affects the brain). During a review of Resident 11's Minimum Data set ([MDS] a standardized care screening and assessment tool), dated 3/13/2024, the MDS indicated, Resident 11'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 five Residents (Resident 11) had a comprehensive assessment completed. This deficient practice of not having a comprehensive assessment completed for Resident 11's contracted neck placed the resident at risk for worsening condition. Findings: During a review of Resident 11's admission Record (Face Sheet), the admission Record indicated Resident 11 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included contractures (a condition of shortening and hardening of muscles, tendons, and rigidity of joints), chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing related problems), and encephalopathy (damage or disease that affects the brain). During a review of Resident 11's Minimum Data set ([MDS] a standardized care screening and assessment tool), dated 3/13/2024, the MDS indicated Resident 11's cognition (ability to learn reason,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 groom one out five Residents (Resident 139). This deficient practice of not grooming Resident 139 had the potential of not receiving the necessary goods and services. Findings: During a review of Resident 139's admission Record (Face Sheet), the Face Sheet indicated Resident 139 was admitted to the facility on [DATE]. Resident 139's diagnoses included aphasia (a language disorder that affects a person's ability to communicate), chronic kidney disease (the kidneys fail to filter waste out the body), and metabolic encephalopathy (an alteration in consciousness caused due to brain dysfunction). During a review of Resident 139's Minimum Data Set ([MDS] a comprehensive assessment and care-screening tool), dated 3/26/2024, the MDS indicated Resident 139 was not able to cognitively (ability to learn, reason, remember, understand, and make decisions) recall information when asked to repeat information. The MDS indicated Resident 139 was dependent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure a PICC line dressing was changed every 7 days and as needed if the dressing is soiled or lifting at the edges for 1 of 2 sampled residents (Resident 86). This deficient practice had the potential to cause an infection in Resident 86. Findings: During a review of the admission Record, Resident 86 was admitted to the facility on [DATE], with diagnoses that included discitis (an infection of the intervertebral disc space [the area between each individual part of the spine]), and acute respiratory failure (disease or injury that affects breathing). During a review of Resident 86's Minimum Data Set [MDS- a comprehensive assessment and screening tool] dated 3/15/2024, it indicated the resident was cognitively intact (ability to reason, understand, remember, judge, and learn). During a review of Resident 86's Care Plan dated 3/13/24 for Intravenous therapy (medication delivered into the vein) of Vancomycin (a strong antibiotic), 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 there was a physician order for one out of five Residents (Resident 81) to wear an Aspen collar (a device to help the neck to heal by supporting the bones in the neck). This deficient practice of not having a physician order placed Resident 81 at risk for inadequate monitoring. Findings: During a review of Resident 81's admission Record (Face Sheet), the admission Record indicated Resident 81 was admitted to the facility on [DATE] with diagnoses that included spinal stenosis (narrowing of the spinal column that causes pressure on the spinal cord), hydrocephalus (a condition in which excess cerebrospinal fluid buildup), and ataxia (a lack of balance coordination and trouble walking). During a review of Resident 81's History and Physical (H&P), dated 1/19/2024, the H&P indicated Resident 81 had the capacity for medical decision making. During a review of Resident 81's Minimum Data set ([MDS] a standardized care screening and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure an enteric coated (a coating on a medication to prevent it from dissolving in the stomach) medication was not crushed for 1 of 4 residents (Resident 57). This deficient practice had the potential for Resident 57 to experience adverse drug reactions from the medication being administered differently from how they were ordered. Findings: During a review of Resident 57's admission Record, it indicated Resident 57 was readmitted on [DATE] with diagnoses that included cerebral infarction (disrupted blood flow to the brain), and atrial fibrillation (irregular heart rhythm). During a review of Resident 57's History and Physical, dated 5/22, it indicated Resident 57 does not have the capacity to understand and make decisions. During a review of Resident 57's Medication Administration Record, dated 5/11/23, it indicated Resident 57 is receiving Aspirin Enteric Coated ([EC]- a coating on a medicine to prevent absorption in the stomach) Tablet…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 up with the Pharmacist's Medication Regiment Review ([MRR] an evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences associated with medication) for one out of five Residents (Resident 8). This deficient practice of not following the MRR recommendations had the potential for Resident 8 to have an adverse effect from not reviewing the insulin sliding scale (varies the dose of insulin based on blood glucose level). Findings: During a review of Resident 8's admission Record (Face Sheet), the admission Record indicated Resident 8 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included type 2 diabetes mellitus (a condition the body in which the body has trouble controlling blood sugar), chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing related problems), and heart failure (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.

Based on observation, interview, and record review, the facility did not ensure an expired and discontinued bottle of Pro-Stat (Concentrated Liquid Protein Medical food) was discarded from medication cart #3. This deficient practice had the potential for unintentional administration of the expired and discontinued medication which can result in adverse drug effects. Findings: During a concurrent observation and interview on 4/4/24 at 1:15 pm, with Licensed Vocational Nurse (LVN) 4, medication cart #3 was inspected. A bottle of expired Nutricia Pro-Stat Concentrated Liquid Protein Medical Food was found with an expiration date of 3/30/24. LVN 4 stated it is not okay to have expired medication in the cart because if a resident receives an expired medication, it will not have the appropriate effect. During an interview on 4/5/25 at 11:26 am, the Director of Nursing (DON), stated the medication carts should be inspected on their shift by the LVN and if it is expired, they need to properly dispose of it and get a new bottle, and if the medication is discontinued, they need to properly…

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