Golden Harbor Healthcare Center

Based on observation, interview, and record review, the facility failed to implement their policy and ensure safety of self-administered medication for one resident (Resident 40) out of a census of 94, when Resident 40 self-administered insulin lispro (a fast-acting insulin to treat diabetes) without a physician's order, evaluation by the Interdisciplinary Team (IDT, a group of professionals, including the resident, their family, physicians, nurses, social workers, and therapists, who collaborate to develop, implement, and monitor the resident's individualized care plan) and applicable care planning. This failure increased the potential for Resident 40 to not receive the full therapeutic effect of the medication, and risk of injury and infection from the incorrect administration of medication.During a medication pass observation on 8/25/25 at 12:08 p.m. with Licensed Vocational Nurse 1 (LVN 1), LVN 1 was observed preparing insulin lispro for Resident 40. LVN 1 stated Resident 40 usually self-administered his insulin. LVN 1 drew seven units from the insulin lispro vial with a syringe…

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 two of 51 sampled residents (Residents 10 and 13) was free from unnecessary psychotropic medication (drugs that affects brain activities associated with mental processes and behavior) when1. Resident 10 received Cymbalta (a psychotropic medication to treat depression) without implementation of non-pharmacological (non-drug) interventions in an effort to lower the dose or discontinue the medication.2. Resident 13 did not have the appropriate indications for the use of Seroquel (Seroquel is an antipsychotic medication; antipsychotic medications are medications that are used to treat symptoms of psychotic mental disorder such as delusions, hallucinations, paranoia, or confused thoughts).These failures had the potential to result in unnecessary use of medication.1.A review of Resident 10's medical record indicated he was admitted to the facility in May 2025 with diagnoses including depression, diabetes and high blood pressure. A review of Resident…

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

Based on observation, interview and record review the facility failed to ensure one sample resident's (Resident 50) / out of 51 residents, English / Chinese picture board for communication was utilized to effectively communicate with others. This lack of effective communication resulted in Resident 50 feeling unable to communicate with staff and experiencing frustration. During an interview on 8/26/25 at 10:30 a.m. at the facility Resident Council meeting, Resident 50 stated she had a difficult time communicating with and understanding the staff. Resident 50 was noted to be articulate a with hearing deficit.During a record review of Resident 50's admission Record (AR), the AR indicated. Resident 50 was admitted to the facility in December 2025 with a diagnosis of metabolic and toxic encephalopathy (condition where the brain doesn't work properly because there's too much or too little of something in the blood (like sugar, oxygen, or toxins). It can happen due to things like liver or kidney failure, infections, or exposure to harmful substances.), delirium (sudden and serious change…

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, for one of one sampled resident (Resident 14), the facility failed to provide treatment and care consistent with professional standards of practice when a resident was provided a wheelchair (w/c) that was inappropriate for resident's size. This failure had the potential to compromise Resident 14's safety and support while up in the w/c. A record review of Resident 14's admission Record' (AR), printed on 8/27/25, AR indicated resident 14 was admitted to the facility in November 2024 with multiple diagnoses that included diabetes mellitus (high blood sugar), dementia (memory loss), and muscle weakness. A review of Resident 14's Minimum Data Set (MDS, an assessment tool used to direct resident care), dated 7/28/25, indicated Resident 14 was able to understand others and be understood. The MDS indicated that the resident had a Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score or 13-15…

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 a safe environment was provided for one of three sampled residents (Resident 57) when:1. Licensed Vocational Nurse 4 (LVN 4) failed to assess Resident 57 immediately after CNA 1 reported resident's unwitnessed fall incident. 2. CNA 1 assisted Resident 57 back to the chair without the appropriate Licensed Nurse knowledge and assessment, following the resident's unwitnessed fall to the floor in the resident's room.These failures resulted in delay in receiving the appropriate medical interventions necessary to meet the resident's nursing care needs and potentially placing Resident 57 at risk for further harm or injury post fall. A record review of Resident 57's admission Record printed on 8/27/25, the AR indicated Resident 57 was admitted to the facility in July 2025, with diagnoses that included alcohol dependence with alcohol-induced disorder (refers to a presentation of alcohol dependence in which a person is not currently experiencing acute complications such as intoxication, withdrawal, or…

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

Based on observation, interview and record review, the facility failed to ensure one of 51 sampled residents call light (Resident 89) was answered promptly. This failure had the potential for Resident 89's needs not to be met in a timely manner and had the potential to result in skin injuries. During an initial tour of the facility on 8/25/25 at 10:23 a.m. in Resident 89's room, the resident stated she had to wait for a long time before her call light was answered, and also, stated she had to wait a long time for her incontinent briefs to be changed. Call light response time was tested, and Resident 89 pressed her call light at 10:25 a.m. The Assistant Director of Nursing (ADON) was observed to answer the resident's call light at 10:48 a.m. The ADON stated it was not acceptable for the resident to wait for 23 minutes (the amount of time that had passed from 10:25 a.m. until 10:48 a.m.) to have her needs attended by the staff. Also stated the call light should be answered promptly due to risk of unattended needs. The ADON had also shown the call light monitor in the nurses' station…

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 provide treatment and care in accordance with professional standards of practice for one of one sampled resident (Resident 1) when: 1. Resident 1 did not receive a medication called albuterol sulfate (used to prevent and treat wheezing, a high-pitched sound that occurs during breathing when the airways in the lungs become narrowed or blocked, and shortness of breath caused by breathing problems) inhalation according to physician's order. 2. Resident 1's oxygen saturation (amount of oxygen you have circulating in the blood) level was not monitored from 1/27/25 to 1/29/25 appropriately when Resident 1 had complaints of shortness of breath and wheezing. This failure had the potential to worsen Resident 1's respiratory condition. Findings: During a record review of Resident 1's admission Record , printed on 2/25/25, the admission Record indicated Resident 1 was admitted to the facility in January 2025 with multiple diagnoses including osteomyelitis (inflammation or swelling that occurs in the bone) of left ankle…

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, interviews, and record review, the facility failed to provide pharmaceutical services and procedures that assure accurate dispensing and administration when Resident 1's Inhaler medication [Albuterol Sulphate ( Medication that helps with breathing by relaxing the muscles of the airways)] was not available on hand per physician's order. This failure had the potential to cause Resident 1's worsened respiratory condition including respiratory arrest (occurs when breathing stops). Findings: During a record review of Resident 1's admission Record , printed on 2/25/25, the admission Record indicated Resident 1 was admitted to the facility in January 2025 with multiple diagnoses including osteomyelitis (inflammation or swelling that occurs in the bone) of left ankle and foot, type II diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar), and lobar pneumonia (a type of lung infection that affects one or more lobes of the lungs). During a record review of Resident 1's Order Summary , dated 3/6/25, the Order Summary indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to identify and address a potential accident hazard when Activity Assistant (AA) 1 did not take the appropriate action to prevent accidents after Resident 1 inquired about purchasing a firearm and if the AA knew where or from whom a gun could be obtained. This failure placed the facility ' s 63 residents at risk for harm and injury when a gun and ammunition were found in Resident 1's room. Findings: During a review of Resident 1 ' s admission Record, printed 11/11/24, the record indicated Resident 1 was admitted [DATE] with multiple diagnosis including a primary diagnosis of paraplegia, complete (the loss of muscle function in the lower part of the body including both legs). During a review of Resident 1 ' s Brief Interview for Mental Status (BIMS, is a scoring system used to determine the resident ' s cognitive status in regard to attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication…

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 there was Registered Nurse (RN) coverage eight hours a day, seven days a week, when an RN was not on duty for eight of 12 days sampled. This failure has the potential to endanger the health and safety of residents while presenting a threat to residents from reaching their highest practicable level of well-being. Findings: During a concurrent interview and record review, on 5/17/2024, at 11:20 a.m., with Payroll (PAYROLL), payroll data was reviewed from Q1/2023 (January - March) until Q1/2024 (January - March). A random sample of dates were chosen for review for each quarter. Payroll confirmed there was no RN scheduled for the following dates: 1. For the month of July 2023: 7/10/23, 7/12/23, 7/13/23 2. For the month of August 2023: 8/24/23, 8/25/23, 8/28/23 3. For the month of October 2023: 10/27/23, 10/30/23 During an interview on 5/17/24, at 11:59 a.m., with Director of Nursing (DON), DON stated there has be an RN in the facility eight hours a day.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement a comprehensive person-centered care plan to address the risk of elopement (leaving a facility without staff knowledge) for two (Resident 52 and Resident 4) out of three sampled residents, when 1. Resident 52's Wanderguard (a type of alarm to help protect those at risk for elopement) interventions were not implemented and Resident 52 eloped from the facility. 2. Resident 4's Wanderguard interventions were not implemented. These failures resulted in Resident 52 eloping from the facility for almost one hour without staff knowledge (Cross reference F689) and had the potential for Resident 4 to elope from the facility which could result in injury and/or death. Findings: 1. A review of Resident 52's admission Record indicated Resident 52 was admitted to the facility with diagnoses of alcoholic cirrhosis of the liver (liver damage caused by alcohol) and encounter for palliative care (care focused on pain and symptom relief of an illness rather than…

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 a system of records for controlled drugs (medications regulated by the government due to high risk for potential abuse and dependence) for disposition were followed and maintained when three Controlled Drug Logbook (CDL) pages of the Narcotics Destruction Log (NDL) were not consistently completed with date of Director of Nursing Services (DNS) receipt of controlled medications, no co-signatures by the licensed nurse and DNS upon exchange of controlled medications, and no page number. The failure to complete three CDL pages listing a total of 43 medications had the potential to prevent accurate accounting of controlled medications and prompt identification of loss, extent of loss, or potential diversion of controlled medications. Findings: During a concurrent interview and record review on 5/16/24 at 8:44 a.m., with the Director of Nursing (DON), at the DON's office, the Narcotics Destruction Log (NDL) binder was reviewed. The pages in the NDL were titled Controlled Drug Logbook (CDL). The three CDL pages contained 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 three of 18 sampled residents (Residents 33, 23, and 28) residents were free from unnecessary psychotropic drugs (medications that are capable of affecting the mind, emotions, and behavior) when: 1. Resident 33's PRN (pro re nata [a Latin phrase], meaning as needed, or as necessary) order for Olanzapine (an anti-psychotic medication used to treat mental disorders) had no end date. 2. Resident 23 had no rationale for continued use of PRN Ativan beyond 14 days (Ativan is a psychotropic medication used to treat anxiety). 3. Resident 28 had no rationale for continued use of PRN Ativan beyond 14 days. These failures had the potential to not promote or maintain Resident 33's highest practicable mental, physical, and psychosocial well-being. Findings: 1. Review of Resident 33's History and Physical (H&P), dated 4/16/24, indicated past medical history of Diabetes Type II and Dementia (impaired memory and thinking abilities). The H&P also included 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.

Based on observation, interview, and record review, the facility failed to ensure medications were dated and stored under proper temperature controls in the medication refrigerator for one of two medication rooms (a locked room used to store medications and supplies) when: 1. Medication refrigerator temperatures were not monitored daily for nine days out of 31 days in May 2024. 2. Two multiple dose vials of Tuberculin Purified Protein Derivative (PPD, a test used to detect tuberculosis (an illness that affects the lungs), were not labeled with the date the vials were opened. These failures had the potential to result in resident use of ineffective medications. Findings: 1. During a concurrent interview and record review on 5/13/24 at 2:09 PM, with the Infection Preventionist (IP), the Temperature Log, for the medication refrigerator was reviewed. The Temperature Log indicated, Medication Fridge Temperature Acceptable Range: 36°F - 46°F. The IP stated there were no refrigerator temperature records documented on the following days in May 2024: May 1, 3, 5, 6, 7, 8, 9, 10, 11. During…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, the facility failed to update and revise four of 16 sampled resident (residents 10, 23, 29 and 34) care plans. These failures had the potential for Residents 10, 23, 29 and 34 to receive inappropriate interventions to manage care. Findings: During a record review of Resident 34's admission Record dated 3/22/22, the admission Record indicated Resident 34 was admitted on [DATE]. During a record review of Resident 34's Minimum Data Set (MDS, an assessment tool used to guide care), the Functional Status dated 2/25/22 indicated Resident 34 needed extensive assistance and total dependence with bed mobility, transfer, locomotion on and off the unit, toilet use and personal hygiene and bathing. During a concurrent interview and record review on 3/23/22, at 1:14 p.m., with the Director of Nursing (DON), of Resident 34's Activities of Daily Living (ADL) Self Care Performance Deficit Care Plan, revised 11/21/21, indicated the care plan was not updated since 11/21/21. DON stated the care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to ensure five (Residents 19, 23, 24, 36, and 39) sampled residents were provided a shower as scheduled for dependent residents. This deficient practice placed residents at risk for poor hygiene, body odor and psychosocial discomfort. Findings: During the resident's council meeting on 3/22/22 at 10:32 a.m., four residents in attendance stated they received showers once a week, and when the facility was short of staff they did not get showered. Review of Annual Minimum Data Set (MDS - an assessment screening tool used to guide care), dated 7/16/21, indicated: Resident 19 required one-person, physical assist with transfer between surfaces, including to and from bed, chair, wheelchair and standing. Resident 19 required physical help with bathing activity. Review of the MDS dated [DATE] indicated Resident 23 required one person, physical assist with transfer between surfaces, including to and from bed, chair, wheelchair and standing. Resident 23…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure three sampled residents (Resident 19, 24 and 36) received behavioral health care and services when Resident 19, 24 and 36 had not received a psychiatrist (physician specializing in mental health) evaluation as planned and ordered by the physician. This deficient practice had the potential to cause residents continued emotional distress. Findings: During a residents council meeting on 3/22/22 at 10:35 a.m., Resident 36 stated living in the facility was hard, especially during COVID-19 (a virus causing respiratory illness and outbreak that is easily spread) outbreaks when residents were in their rooms all the time. Resident 36 stated most of the residents at the facility have behavioral issues. Resident 36 stated the facility did not provide much needed counseling for residents. Review of Resident 19's Minimum Data Set (MDS- an assessment and care screening tool used to guide care), dated 1/16/22 indicated, Resident 19 had 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.

Based on interview and record review, the facility failed to follow the policy and procedure to conduct infection control surveillance when they did not track, analyze, and create infection control data. This deficient practice had the potential for infections to go undetected or controlled which could spread within the facility. Findings: During an interview and concurrent record review with the Infection Preventionist (IP), on 3/24/22 at 10:30 a.m., IP stated and showed the infection control surveillance was last documented in August 2021. IP stated she could not provide documentation of conducting infection control surveillance from September 2021 to currently. IP stated she was new to the facility and was trying to contact the previous IP about the infection control surveillance records, but was unsuccessful. During an interview with Registered Nurse 1 (RN 1), on 3/24/22 at 12:15 p.m., RN 1 stated the infection control surveillance should be done monthly to make sure there were no outbreaks. During an interview with RN 1 on 3/24/22 at 12:23 p.m., RN 1 stated she could not find…

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 follow the policy and procedure to implement antibiotic stewardship when they did not monitor appropriate use of antibiotics and improved outcomes for residents. This deficient practice had the potential to spread infection in the facility. Findings: During an interview and concurrent record review with the Administrator (Admin), on 3/24/22 at 10:43 a.m., Admin stated she could not find documentation that their antibiotic stewardship was done in September, October and November of 2021. During an interview with the Registered Nurse 1 (RN) 1 on 3/24/22 at 12:15 p.m., RN 1 stated the antibiotic stewardship monitoring should be done monthly to make sure there were no outbreaks and to make sure the use of antibiotics were needed. During an interview with Admin on 3/24/22 at 12:16 p.m., Admin stated antibiotic stewardship monitoring should be done to make sure antibiotics were not used unnecessarily. During an interview with RN 1 on 3/24/22 at 12:23 p.m., RN 1 stated she could not find the antibiotic stewardship binders 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.

Based on interviews and record review, the facility failed to make reasonable effort to safeguard the resident's property for one (Resident 36) sampled resident when Resident 36 complained of missing socks which was not investigated. This deficient practice had the potential to cause Resident 36 distress. Findings: During a resident's council meeting on 3/22/22 at 10:35 a.m., one resident stated the facility did not follow up with their report of missing clothing items. Resident 36 stated she reported to the Social Services Director (SSD) that her socks were missing. Resident 36 stated SSD did not follow up with her complaint or replace her clothing item. Review of the Annual Minimum Data Set (MDS - an assessment screening tool used to guide care) dated 12/29/21, indicated Resident 36's Basic Interview of Mental Status (BIMS) score was 15, meaning the resident had good long and short term memory. Resident 36 was able to express her ideas and wants and had clear speech. During an interview on 3/24/22 at 10:49 a.m., SSD stated she was aware of Resident 36's missing socks and could 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.

Based on interview and record review, for one of three residents (Resident 49) reviewed for closed records, the facility failed to notify Resident 49's representative of the decision to transfer Resident 49 to the hospital. This failure had the potential to result in the representative being unaware of changes in Resident 49's health status and whereabouts. Findings: Review of admission Record indicated Resident 49 was admitted to the facility with diagnoses that included a subarachnoid hemorrhage (bleeding in the space that surrounds the brain), dysphagia (difficulty swallowing), and acute respiratory failure (when fluids build up in the air sacs in the lungs). Resident 49's admission Record indicated Resident Representative (RR) 1 was Resident 49's emergency contact. Review of the Progress Notes titled, SBAR (situation, background, assessment and recommendation) Change of Condition dated 12/22/21, indicated Resident 49 had severe cramping to the right side groin area with protrusion of the area and very tender to touch. Resident 49 was transferred to the acute hospital via 9-1-1.…

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 interview and closed record review, for two of three sampled residents, (Residents 47 and 49), the facility failed to: 1. Notify in writing, Resident 47 and Resident's Representative 2 (RR 2) of the reason for the discharge in Resident 47's clinical record. 2. Notify in writing, Resident 49 and RR 1 of the hospital transfer. These failures had the potential to result in lack of information to prepare the residents and their resident representatives following the discharge or hospital transfer. Findings: 1. Review of Resident 47's admission Record indicated Resident 47 was admitted to the facility with diagnoses that included Alzheimer's dementia (memory loss and impaired decision-making ability), and pneumonia (infection of the lungs caused by bacteria, virus or fungi). Review of Resident 47's Progress Notes Dated 12/21/21 indicated Resident 47 was picked up by ambulance and discharged to a board and care. During an interview with the Social Services Director (SSD) on 3/23/22 at 3:09 p.m., SSD stated Resident 47 and RR 2 were not notified in writing about the reason for…

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

Based on interview and closed record review, for one of three sampled residents (Resident 49), the facility did not provide Resident 49 and Resident Representative 1 (RR 1) written information about the facility's bed hold policy before and upon transfer to the hospital. This failure had the potential to result in Resident 49 being unaware of the right to return to the facility during a therapeutic leave according to the bed-hold policy. Findings: Review of the admission Record indicated Resident 49 was admitted to the facility with diagnoses that included subarachnoid hemorrhage (bleeding in the space that surrounds the brain), dysphagia (difficulty swallowing), and acute respiratory failure (when fluids build up in the air sacs in the lungs). Resident 49's admission Record indicated RR 1 was Resident 49's emergency contact. Review of the Progress Notes Situation, Background, Assessment, Review (SBAR), a communication process among healthcare professionals) Change of Condition dated 12/22/21, indicated Resident 49 had severe cramping to the right side groin area with protrusion 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.

Based on interviews and record review, the facility failed to ensure the Minimum Data Set (MDS-Resident Assessment and Care Screening tool used to guide care), was accurate for one ( Resident 24) sampled resident when Resident 24's preadmission screening for serious mental illness was not coded accurately. This deficient practice had the potential for residents to not received appropriate mental health care and services. Findings: Review of the Annual Minimum Data Set, MDS - resident assessment tool used to guide care, dated 7/28/21, indicated section A- Preadmission Screening and Resident Review (PASRR) was coded zero which indicated Resident 24 was not currently considered by the state level 11 PASRR process to have a serious mental illness. Resident 24's diagnoses included schizophrenia, (a long term mental disorder of a type involving a breakdown in the relation between thought, emotion, and behavior leading to faulty perception, withdrawal from reality into fantasy and delusion and a sense of mental fragmentation). Review of the State of California-Department of Health Care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, for one of two sampled residents (Resident 27) reviewed for PASRR (Pre-admission Screening and Resident Review (a screening tool to determine if individuals with serious mental illness or intellectual/developmental disability or related condition require nursing facility services or specialized services), the facility failed to follow-up on PASRR level II screening as determined by Resident 27's PASRR Level I screening. This failure had the potential to result in Resident 27 not being provided specialized care and services to address a mental illness. Findings: Review of Resident 27's admission Record indicated Resident 27 was re-admitted to the facility on [DATE] with diagnoses that included bipolar disorder (mental health condition that causes extreme mood swings that include emotional highs and lows), depression (persistently depressed mood and loss of interest in activities) and anxiety disorder (feelings of worry, anxiety or fear strong enough to interfere with daily…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, for one of four sampled residents (Resident 14), the facility failed to implement a comprehensive person-centered care plan to address Resident 14's weight gain. This failure resulted in further weight gain that was not addressed appropriately. Findings: Review of Resident 14's admission Record indicated Resident 14 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus (blood sugar disorder), hypothyroidism (thyroid gland does not produce enough thyroid hormone, and major symptoms include fatigue, constipation, dry skin and unexplained weight gain), and heart failure. Review of Resident 14's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 1/8/22, the Swallowing/Nutritional Status, indicated Resident 14 had a weight gain of five percent (5%) or more in the last month or 10 % or more in the last six months. The MDS also indicated Resident 14 was not on a physician-prescribed weight gain regimen. Review of Resident…

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

Based on observation, interview, and record review, for one (Resident 30) of one sampled resident reviewed for skin issues, the facility failed to ensure treatment and care were provided in accordance with the resident's choice when skin care was not provided to address Resident 30's dry skin. This failure had the potential to result in skin breakdown. Findings: Review of Resident 30's admission Record indicated Resident 30 was admitted to the facility with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD, a chronic lung disease that obstructs airflow from the lungs) and Chronic Kidney Disease. Review of Resident 30's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 2/6/22, indicated Resident 30 had a Brief Interview for Mental Status (BIMS, an assessment of resident's orientation to time and capacity to remember) score of 15, meaning no cognitive impairment. During an observation and concurrent interview with Resident 30, on 3/21/22 at 111:20 a.m., Resident 30's feet had very dry, flaky skin. Resident 30 stated having asked the staff…

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 nursing staff had the appropriate competencies and skills sets for providing care to residents when staff training for behavioral services were not provided. This failure had the potential to result in inappropriate care that did not meet the needs of the residents with behavioral issues. Findings: Review of the facility's Facility Assessment, last reviewed 11/25/21, indicated the services provided by the facility included mental health and behavior services, specifically behavior management. Furthermore, the facility would ensure staff competencies to include caring for residents with mental and psychosocial disorders, residents with history of trauma and post-traumatic stress disorder, and non-pharmacological interventions to address behaviors. During an interview and concurrent review of the staff training records with the Infection Preventionist (IP), on 3/24/22 at 11:52 a.m., IP stated she began working at the facility on 3/21/22 and has yet to audit staff competencies. IP stated she could not find the record…

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

Based on interviews and record review, the facility failed to ensure two (Residents 27 and 36) sampled residents were free from unnecessary drugs when: 1. Resident 36 was administered trazodone (anti-depressant and sedative medication) for insomnia (inability to fall asleep or stay asleep) without adequate monitoring for hours of sleep. 2. Resident 27 behavioral symptoms were not monitored for the use of lorazepam (anti-anxiety medication). This deficient practice had the potential for residents to receive unnecessary drugs or the appropriate medication dosage to manage their condition which could have adverse side effects. Findings: 1. Review of Resident 36's Minimum Data Set (MDS- an assessment and care screening tool used to guide care), dated 12/29/21 indicated, Resident 36 had trouble falling or staying asleep, or sleeping too much. Resident 36 diagnoses included anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) and depression (sadness or loss of interest). Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to remove expired medication for one of 16 residents (Resident 31). This failure had the potential to result in Resident 31 being given expired medication and did not ensure safe medication administration. Findings: During a record review of Resident 31's admission Record dated 3/24/22, the admission Record indicated Resident 31 was admitted on [DATE]. During a record review of Resident 31's Order Summary Report dated, 3/24/22, which indicated Resident 31 had a discontinued doctor's order for Heparin (blood thinner) Sodium (Porcine) Solution 5000 unit/milliliter ordered on 10/19/21. During a concurrent observation and interview, on 3/23/22, at 10:45 a.m., in the Medication Room, with the Infection Preventionist (IP), Resident 31's Heparin was observed to have an expiration date of 2/22. IP stated Resident 31's Heparin expired February 2022, and was not supposed to keep expired medications in the medication room. IP further stated the expired…

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

Based on interview and record review, for one of four sampled residents (Resident 14), the facility failed to obtain physician ordered laboratory tests. This failure resulted in not monitoring and reporting potential abnormal test results. Findings: Review of Resident 14's admission Record indicated Resident 14 was admitted to the facility with diagnoses that included diabetes mellitus (blood sugar disorder), hypothyroidism (thyroid gland does not produce enough thyroid hormone, and major symptoms include fatigue, constipation, dry skin and unexplained weight gain), and heart failure. Review of the History and Physical by Resident 14's physician dated 3/17/22, indicated under assessment/plan, Resident 14 needed labs (laboratory tests) that included TSH ( thyroid test), Free T4 (another thyroid test), HgbA1C (test for diabetic sugar control over a few months), CMP, CBC (Complete Blood Count), a test to check several components of the blood, like red blood cells), lipid panel (cholesterol, a waxy substance in the blood) and triglycerides (type of fat). Review of Resident 14's…

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

Based on interviews and record review the facility failed to ensure the staff skills competency evaluations were completed for one [NAME] (CK 1). CK 1's competency evaluation was not completed before food preparation of the residents' meals. This deficient practice had the potential to result in food preparation under unsanitary conditions or foodborne illness. Findings: During an observation of the tray line, on 3/22/22 at 11:49 a.m., in the presence of the Dietary Supervisor (DS) and Dietician (RD), [NAME] 1 used the same paper towel to clean the thermometer while checking the prepared food temperatures. During an interview on 3/22/22 at 11:49 a.m., [NAME] 1 stated she was sorry and forgot to use alcohol wipes to clean the thermometer. Note: Checking the temperature without cleaning the thermometer probe between readings can lead to microbes being transferred from contaminated items to those that are thought to be safe or cross contamination). During an interview on 3/22/22 at 8:34 a.m., DS stated he did not document the skills competency evaluations for the dietary staff. 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.

Based on interview and record review, for one of three sampled residents (Resident 42) reviewed for advanced directives, the facility failed to ensure Resident 27's clinical record was complete when the POLST (Physician Order for Life-Sustaining Treatment) form was not completed and signed. This failure had the potential to result in Resident 42 receiving care against her wishes. Findings: Review of Resident 42's admission record indicated Resident 42 had been known to the facility since August 2021. Resident 42 was admitted with diagnoses that included malignant neoplasm of central nervous system (condition when abnormal cells form in the brain or spinal cord) and acute ischemic heart disease (blockage of blood flow to the heart). Resident 42 had contracted COVID-19 (viral respiratory infection that could cause severe complication including death) after being admitted to the facility. Review of the Physician Orders dated 3/15/22 indicated an order for the POLST (Physician Order for Life-Sustaining Treatment, a standardized medical order that indicates specific type 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.

Based on interview and record review, the facility's quality assessment and assurance committee did not meet quarterly as required. This failure had the potential to result in not identifying quality of care issues and follow up on set goals. Findings During an interview and concurrent review of the facility's records with the Administrator (Admin), on 3/24/22 at 12:42 p.m., Admin stated the facility's last quality assurance (QA) meeting was in November 2021. Admin stated, the QA meetings were to be done every quarter, and the next one would have been done in February 2022. Admin further stated there was no record of the QA meeting having occurred in February 2022.