La Crescenta Healthcare Center

Based on observation, interview, and record review, the facility failed to ensure the facility's waste dumpsters cover were kept closed and not exposed to elements in the trash area. This failure had a potential to result in pest infestation [an increase in the numbers of a pest species (insect or small animal that is harmful, such as rats, mice, or cockroaches) in a given area], odors, unsanitary environment, and a spread of bacteria (small living things that could be dangerous and cause illnesses) and insects (small animals such as ants, and flies). Findings: During an observation on 4/22/2025 at 10:20 AM in the facility ' s trash area, the blue waste dumpster was overflowing with trash, and the lid was not closed. One of two facility ' s black waste dumpsters was not closed with lid. During an interview on 4/22/2025 at 2:35 PM with the Administrator (ADM), the ADM stated, she was responsible to do the facility ' s round in the trash area to make sure the facility ' s waste dumpsters were closed and the area surrounding the trash area was clean. The ADM stated, she got a report…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow the facility ' s policy for Infection Control Program and Hand Hygiene for six of 16 sampled residents ' (Resident's 57, 35, 30, 66,41, and 64) during dinning observation in the Front Dining Room (FDR) by failing to ensure: 1. The Activity Director (AD) who was observed serving, preparing food trays and touching Resident's 57, 35 and 30 without performing hand hygiene before and after direct contact. 2. Director of Staff Development (DSD) was observed serving, preparing food trays and touching Resident's 66, 41 and 64 without performing hand hygiene before and after direct contact. This deficient practice had the potential to cause and/or spread infection (a process when a microorganism, such as bacteria, fungi, or a virus, enters a person's body and causes harm) in the facility. Finding: During a review of Resident 57's admission Record, indicated the facility admitted Resident 57 on 2/18/2022 with diagnoses that included 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.

Based on observation, interview, and record review, the facility failed to maintain the facility ' s dishwasher in operating condition to keep in a safe and efficient manner when the dishwasher failed the chlorine sanitizer (an effective, chlorine-based, substance or product used to reduce the number of harmful germs on all food contact surfaces to a safe level when cleaned and processed through an approved ware wash operation) test on 4/22/2025 at 9:05 AM. This failure had a potential to result in the facility ' s foodware (items used for containing, serving, or consuming prepared food, including cups, bowls, plates, etc.) and cookware (pots, pans, and other utensils used for cooking food) were not cleaned and sanitized, which could lead to a wide spread of foodborne illness (a condition that occurs when consuming contaminated food or beverages, which caused by the ingestion of harmful germs) within the facility ' s residents. Findings: During an observation on 4/22/2025 at 9 AM with the Dishwasher Aid (DA 1) in the kitchen, the dishwasher ' s water temperature was at 120 degrees…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to follow the facility ' s policy and procedure for self-administration of medications for one out of one sampled resident (Resident 75) when: 1. Resident 75 was not assessed prior to self-administration of medications. 2. Resident 75 was observed storing medications at the bedside. This deficient practice had the potential for Resident 75 and other resident who can have access to the medications to be at risk of harm from potential side effects or adverse effect (undesired effect of medication) that the medications could pose on Resident 75. Findings: A review of Resident 75 ' s admission Record indicated the resident was admitted on [DATE] with diagnoses that included right leg wound, left leg fracture (break in the bone), and hypertension (elevated blood pressure). A review of Resident 75 ' s History and Physical (H&P), dated 9/28/2024, indicated the resident does have the capacity to understand and make decisions. A review of Resident 75…

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 2. A review of Resident 33's admission Record, indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia (a gradual decline in mental ability usually caused by a brain disease), Parkinson's disease a brain disorder in which there is a lack of the chemical messenger dopamine, which helps control muscle movement; leads to muscle stiffness, weakness, and trembling), and osteoarthritis (inflammation of the joints due to the breakdown of the cartilage lining the bones in joints). A review of Resident 33's H&P, dated 11/27/2024, indicated the resident has a history of fractures (a break in a bone). The H&P also indicated the resident has a history of mental illness. A review of Resident 33's MDS, dated [DATE], indicated Resident 33 has severely impaired cognition (the ability to think and process information). The MDS also indicated that the resident is dependent on activities such as toileting and bathing and required substantial/maximal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan to address Resident 32's refusal to have the long nails with fungal infection and for podiatric (a physician specialized in foot treatment) treatment on 7/13/2024, 8/24/2024, 10/24/2024 and 1/7/2025 (total 4 days). This deficient practice had a potential result in Resident 32's inadequate and incomplete provision of care and result in worsened foot infection and pain. Findings: During a review of Resident 32's admission Record, indicated Resident 32 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included postherpetic trigeminal neuralgia (a condition characterized by persistent, severe facial pain that can develop after a shingles [a viral infection that causes a painful, blistering rash that typically appears on one side of the body] outbreak), secondary parkinsonism (a condition where symptoms similar to Parkinson's disease [like tremors,…

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 respiratory care and treatments in accordance with the professional standards of practice, care plan goals, physician's order and the facility's policy and procedure for one of one sample residents (Resident 78) who was observed without oxygen for more than 30 minutes, while pulse oximeter reading (a measure of how much oxygen is carried by red blood cells in the blood, expressed as a percentage, with a normal range being 95-100%) decreased to 85%. The Physician ordered Resident 78 to receive oxygen at 2 liters (standard unit used to measure the rate of oxygen flow) as needed for shortness of breath or oxygen saturation less than 93 percent. This deficient practice had the potential for Resident 78 to experience hypoxia (not enough oxygen is available to meet the needs of the body's cells) and/or respiratory distress (difficulty breathing), hospitalization and death. Findings: During a review of Resident 78's admission Record,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain a medication error rate of five percent or (5%) or less during medication pass for two of four residents (Residents 28 and 237) in which three (3) medication errors were identified out of 30 opportunities which yielded a cumulative error rate of 10 %. Licensed Vocational Nurse (LVN) 1 checked the heart rate of Resident 237 prior to the administration of Hydrochlorothiazide (medication that lowers the blood pressure and heart rate) and Verapamil (medication ordered to manage hypertension [HTN- elevated blood pressure]) LVN 1 verified the dosage of Cyanocobalamin B12 (a vitamin supplement) according to the physician's order, the Medication Administration Record (MAR) and the medication available prior to administration of of to Resident 28's. Findings: 1. A review of Resident 237's admission Record indicated the resident was admitted on [DATE] with diagnoses that included heart disease (the build-up of fats, cholesterol, and other…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of four observed residents (Residents 237) was free from any significant medication errors when Licensed Vocational Nurse (LVN) 1 did not check the heart rate of Resident 237 prior to the administration of Hydrochlorothiazide (medication that lowers the blood pressure and heart rate) and Verapamil (medication ordered to manage hypertension [HTN- elevated blood pressure]). This deficient practice had the potential for the resident have dangerously decreased blood pressure and heart rate that could result in hospitalization and death. Findings: 1. A review of Resident 237's admission Record indicated the resident was admitted on [DATE] with diagnoses that included atherosclerotic heart disease (the build-up of fats, cholesterol, and other substances in and on the walls of blood vessels) and history of falls. A review of Resident 237's History and Physical (H&P), dated 4/17/2025, indicated the resident has a diagnosis 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 follow their policy and procedure for medication storage when one out of three medication carts was found to have 2 insulin pens (medication to control the blood sugar), belonging to Resident 72, that were not discarded within 28 days from the opened date. This deficient practice had the potential for staff to administer the insulin pens, which may less efficacy and could lead to the mismanagement of the blood sugar of Resident 72. Findings: A review of Resident 72's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar or blood glucose control and poor wound healing) and hyperlipidemia (elevated blood cholesterol). A review of Resident 72's History and Physical (H&P), dated [DATE], indicated the resident does not have the capacity to understand and make decisions. The H&P also indicated the resident has 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 failed to ensure nutritional supplement and food products for two out of three stored in the medication carts were labeled with expiration date, in accordance with the facility's policy and procedure. This deficient practice had the potential for facility staff to administer the food products to residents, which could cause foodborne illnesses (a disease caused by consuming contaminated food or beverages. These contaminations can be from bacteria, viruses, parasites, or harmful chemicals that can cause nausea, vomiting, diarrhea, and fever). Findings: During a concurrent observation and interview on 4/23/2025 at 11:00 AM with Minimum Data Set Nurse (MN), Medication Cart (MC) 3 was examined. The bottom drawer of MC 3 was observed to have a 237 mL carton of Ensure Plus that was opened and undated. MN stated the carton of Ensure Plus did not have any markings that indicated the date it was used and for which resident the Ensure Plus was ordered for. MN stated it must be thrown away because it could be expired, 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 failed to ensure prompt attempts were made to resolve grievances brought by resident representative (Family [FM] 1) for one of three sampled residents (Resident 1) to the facility, and reports/resolution was signed and made available to the resident or FM 1, in accordance to the facility policy and procedure (P&P) titled Grievances and Complaints. This deficient practice violated the resident ' s right to have their grievance properly addressed and resulted in care that did not align with the resident ' s wishes/preferences. Findings: During a review of Resident 1 ' s admission Record (AR), the AR indicated Resident 1 was admitted on [DATE], with diagnoses that included cerebral infarction ( when blood flow to the brain is blocked) , cardiac pacemaker( a small medical device implanted in the chest to regulate abnormal heart rhythms) and Atrial fibrillation ( irregular heartbeat). The AR indicated FM 1 is Resident 1 ' s responsible party. During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to implement the resident ' s care plan to wear protective clothing and/or Geri sleeves to protect skin due to pinching/scratching self and/or when agitated for one of three sampled residents (Resident 1). This deficient practice may have the potential to compromise quality of life, unmet care needs, increased risk of health decline and emotional and psychological distress. Findings: During a review of Resident 1 ' s admission Record (AR), the AR indicated Resident 1 was admitted on [DATE], with diagnoses that included cerebral infarction ( when blood flow to the brain is blocked) , cardiac pacemaker( a small medical device implanted in the chest to regulate abnormal heart rhythms) and Atrial fibrillation ( irregular heartbeat). During a review of Resident 1 ' s History and Physical dated, 4/18/2024, indicated Resident 1 had a diagnosis of dementia. The H&P indicated Resident 1 had fair rehabilitation potential and confused. During a review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to meet professional standards of quality for one of three sampled residents (Resident 3) by failing to ensure medications were administered by licensed personnel only, in accordance the facility policy and procedure (P&P) titled Medication Pass Guidelines. This deficient practice had the potential to result in serious harm, including the risk of injury to the resident due to medication errors that could have occurred. Findings: During a review of Resident 3 ' s admission Record (AR), the AR indicated Resident 3 was admitted to the facility on [DATE], with a diagnoses that included Peripheral vascular disease( a condition where the blood vessels outside the heart and brain become narrowed or blocked), paraplegia ( paralysis affecting one half of the body) and cardiomegaly( an abnormal enlargement of the heart, leading to high blood pressure). During a review of Resident 3 ' s History and Physical (H&P) dated 11/3/2024, the H&P indicated resident had 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 develop and implement a person-centered care plan with individualized interventions that included the dementia (a disorder of mental processes caused by brain disease or injury and marked by memory disorder, Personality changes, and impaired reasoning) care needs with behavioral issues for one of three sampled residents (Resident 1), in accordance with the resident ' s care plans written for dementia and ADL functional /Rehabilitation and the facility ' s policy & procedures (P&P) titled Behavioral Symptoms Associated with Dementia Management. Resident 1 manifested increased in behavior/agitation when care was rendered by registry staff of certain ethnicity as requested and repeatedly filed through the facility ' s grievance process. The facility failed to assess and implement resident centered interventions to address the root cause of Resident 1 ' s increased in behavior symptoms when care was provided by registry staff of certain…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to follow the prescribed diet order for one of three sampled residents (Resident 1). Resident 1, who is on a very low- carbohydrate, double protein, 1200- calorie diet, did not receive meals in accordance with correct order and prescribed portion sizes. This deficient practice resulted in an unintentional weight gain (not on purpose) , potentially delaying recovery from illness or injury. Findings: During a review of Resident 1 ' s admission Record (AR), the AR indicated Resident 1 was admitted on [DATE], with diagnoses that included cerebral infarction ( when blood flow to the brain is blocked) , cardiac pacemaker( a small medical device implanted in the chest to regulate abnormal heart rhythms) and Atrial fibrillation ( irregular heartbeat). During a review of Resident 1 ' s History and Physical dated, 4/18/2024, indicated Resident 1 had a diagnosis of dementia. The H&P indicated Resident 1 had fair rehabilitation potential and confused.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a personal safety alarm (PSA: any physical or electronic device that monitors resident movement and alerts the staff when movement is detected) was placed on one of two sampled residents (Resident 1) bed, who was assessed as a high risk for fall, in accordance to the facility ' s policy and procedure (P&P) titled, Personal Safety Alarm. This deficient practice had the potential for a delayed response from facility staff when Resident 1 attempted to get out of bed unassisted, potentially resulting in falls. Findings: During areview of Resident 1 ' s Face Sheet, the Face Sheet indicated that Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Alzheimer ' s disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), history of pelvis fracture, history of falling, and osteoporosis (a bone disease…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to protect and promote resident rights for 1 of 3 sampled residents (Resident 1) when LVN 1, CNA 2, and CNA 3, continue to change Resident 1 ' s diaper after Resident 1 refused to be changed. This deficient practice resulted in Resident 1 ' s right hand accidentally hit the bedrail (metal or plastic bars positioned along the side of a bed, also commonly known as side rails) and caused bruising (an injury in which the skin is not broken but is discolored from the breaking of small blood vessels that lie underneath the skin) to the back of the right hand and right wrist area. Findings: A review of Resident 1s admission record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but not limit to, cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), depressive disorder (a mental health condition that causes a persistently low or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure food tray was served timely for one of three sampled residents (Resident 4) when Resident 4, who was in the dining room, lunch tray was delivered at 1:00 P (scheduled meal service was 12:15 PM). This deficient practice had the potential to affect the palatability of the food (quality of being tasty or acceptable in some other way), attractiveness and temperature which could decrease food intake and affect Resident 4 ' s nutritional health (the adequate provision of vitamins, minerals, fiber, water carbohydrates, proteins, fats and other micronutrients to cells and organisms, to support life). Findings: A review of Resident 4 ' s admission record indicated the resident was admitted to the facility on [DATE] with diagnoses that included but not limit to autonomic neuropathy (damage to the nerves that control automatic body functions), vitamin D deficiency (inadequate amounts of vitamin D in your body) and muscle wasting (decrease in…

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 report immediately, but not later than 2 hours, all alleged violations involving abuse, including injuries of unknown source to the California Department of Public Health for one of three sampled residents (Resident 1) with increased bruising on the left flank area and new fractures of the ribs on 6/1/24. This deficient practice had the potential for Resident 1 and other residents in the facility to be subject from possible abuse in the facility. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 3/25/24 with diagnoses that included fracture (broken bone) of sacrum (injuries that involve sacral lateral to the foramina (based of the skull), fracture of first and fifth lumbar vertebra (lower back), and thrombocytopenia (a condition in which you have low blood platelet count). A review of Resident 1 ' s the Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 3/31/24, indicated Resident 1 ' s cognitive skill (mental action or process of acquiring…

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 dispose garbage and refuse (food waste, scraps) properly by not covering three of three metal dumpsters (large trash container designed to be emptied into a truck) due to overflowing garbage bags leaving more than 5 trash bags, broken sofa, broken chair, and boxes on the ground next to the dumpster. This deficient practice had a potential to attract birds, flies, insects, pest and possibly spread infection to 87 of 87 facility residents and staffs in the facility. Findings: During an observation on 4/22/2024 at 8:30 AM, three metal dumpsters were not covered due to overflowing garbage bags leaving more than 5 trash bags, broken sofa, broken chair, and boxes on the ground next to the dumpster. During a concurrent observation of the dumpster area located at the back of the facility and with Housekeeping Supervisor (HS) accompanied by Maintenance Supervisor (MS) dated 4/22/2024 at 8:50 AM. HS and MS stated the three-metal dumpster are overflowing with trash bags. HS stated, the three-metal dumpster should not be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an Advance Directives (AD-a written statement of a person's wishes regarding medical treatment to ensure those wishes are carried out should the person be unable to communicate his/her needs to the doctor) and the Physician Orders for Life-Sustaining Treatment (POLST: medical order forms that indicate to the medical staff what to do in an event of medical emergency) were offered and/or obtained and accessible in the residents medical records for 4 of 5 sampled residents (Resident 187, 30, 25 & 74). The facility failed to ensure: 1. Resident's 187 Advance Directive acknowledgement form was not located in the paper chart and POLST was not completed. 2. Resident's 30, 25, and 74 medical records did not include and Advance Directive acknowledgement form. This deficient practice had the potential for residents' medical treatment provisions to not be carried out, according to the resident's request during emergency situations and/or when a resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to provide treatments and services for three out of six sampled residents (Residents 68, 25, and 17) at risk for decline in range of motion (ROM, full movement potential of a joint) and mobility by failing to: 1a. Provide Resident 68 with Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) treatments for passive range of motion (PROM, movement at a given joint with full assistance from another person) exercises on both lower extremities (BLE, hip, knee, ankle, feet) five (5) times a week as ordered. 1b. Provide Resident 68 with RNA treatments to apply both knee extension splint (rigid material or apparatus used to support and immobilize a broken bone or impaired joint to keep the knee in straight position) for three (3) hours or as tolerated once a day 5 times a week. 1c. Follow physician RNA treatment orders to apply both knee extension splints for maximum of three…

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 insure resident's safety through implementation and fire prevention interventions. by identifying and eliminating fire and environmental hazard for two of twelve sampled residents (Residents 35 and 288) by failing to ensure heating units ( a machine used that provide heat in the room) were free and clear of potentially flammable ( materials that can cause fire) items. This deficient practice had a potential to result in a fire that could lead to burns, injury and death to the facility staffs, residents and visitors. Findings: 1. A review of Resident 35s' admission Record indicated the facility admitted Resident 35 on 3/29/2024, with diagnoses that included myocardial infarction (heart attack or interruption of blood flow in the heart) and angina (chest pain), A review of Resident 35's History and physical, dated 4/20/24, indicated the resident has the capacity to understand and make decisions. A review of Residents 35's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 3/18/2024,…

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 an observation, interview and record review, the facility failed to: 1. Ensure the activities recorded in the Controlled Drug Records (the accountability record or count sheet for narcotics) had corresponding administration documentations in residents' electronic medication administration records (eMAR) for two (2) of 29 sampled residents (Residents 46 & 64). 2. Ensure there was a policy, developed and implemented, for the accurate usage of the Emergency Medication Supplies (E-kit). There were missing entries in the E-kit logbook. These deficient practices had the potential for drug diversion (medical and legal concept involving the transfer of any legally prescribed controlled substance from the individual for whom it was prescribed to another person for any illicit use) and/or medication errors. Findings: 1. On 4/23/24 at 2:55 PM, during an observation at of Medication (med) Cart 2 with a Registered Nurse (RN 3), there was a bottle of morphine (an opioid and a potent treatment for pain) concentrate…

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 (1) of 3 medication carts were locked when left unattended in the hallway. Registered Nurse 2 (RN2) prepared the medication and did not lock the medication cart before entering the resident ' s room. These deficient practices had the potential to result in misuse or medication loss by providing the unauthorized staff or person an opportunity to access resident ' s medications. Findings: On 4/23/24 at 8:56 AM during an interview, the registered nurse (RN 2) stated the facility has 2 nursing stations and 3 medication carts. On 4/23/24 at 9 AM during an observation, there was a medication Cart (med cart 1) located outside of a resident room, in the hallway which was accessible by other residents, visitors, and staff. RN 2 finished preparing medications and entered the resident's room without locking the med cart; thus, leaving the med cart unattended in the hallway. On top of the med cart, there were 7 over-the-counter medication bottles on top of the med cart and 1 bubble pack (a blister pack that is…

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 observations, interviews, and record review the facility failed to ensure the kitchen staff were routinely trained and evaluated for competency and skills sets to carry out functions of the food and nutrition service by failing to: a. Staff failed to demonstrate and verbalize the correct procedures in testing the chlorine (a chemical used for disinfectant) for low temperature dish machine. b. Staff failed to verbalize and follow the manufacturer ' s guidelines of QT-40 test strips (a type of test strip) when checking the Quaternary Ammonium Compounds (Quats, a group of chemicals used to disinfect surfaces and equipment) sanitizer concentration. c. Staff failed to verbalize proper cooling procedures of food. These failures had a potential to result to potential cross-contamination (a transfer of bacteria from one object to another), ineffective dish machine, unsanitized food preparation areas and bacterial growth to food that could lead to food borne illness (an illness caused by contaminated food and beverages) in 85 of 85 medically compromised residents who received food…

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

Based on observation, interview, and record review the facility failed to follow the menu for 32 of 85 residents on Regular texture diet (diet that has no restriction in texture and consistency) by not following the portion size for paprika chicken based on the facility ' s menu spread sheet. This deficient practice placed the facility residents at risk of unintended (not done on purpose) weight gain or weight loss and not meeting the physician ' s diet orders causing delay of recovery from illness or injury. Findings: During an observation of the lunch tray line (an area where resident ' s food was assembled) on 4/23/2024 at 12:07 PM, pieces of the chicken in the steam well were not consistent in size, some were small, and some were big for a three (3) ounces (oz, a unit of measurement) size. During a concurrent observation of the weight of the chicken and interview with [NAME] 1 and [NAME] 2 on 4/23/2024 at 12:35 PM, [NAME] 1 stated, their practice was to serve 2 small pieces of the chicken as a serving. [NAME] 1 weigh 2 small chicken pieces using a facility weighing scale and it…

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

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen in accordance with the facility ' s policy and procedure and standard of practice by failing to ensure: 1. Equipment and kitchen cleanliness were maintained: a. Three of 3 storage racks had rust-looking discoloration and stained in the walk-in refrigerator. b. Storage rack where bananas were stored in the preparation area had dust and dirt buildup. c. Storage container for ketchup, mix jelly, creamer and yellow cake mix had food and dirt residue. d. Dry storeroom floors had dirt debris. e. Kitchen hood had grease and dirt buildup. f. Three of 3 vent by the tray line area (food preparation area in which food trays travel around the production line) had dirt buildup. 2. Ensure measures to prevent cross-contamination was maintained: a. Two (2) dented cans were found in the dry storage area and emergency supply room. b. Scoop and tong handles were not stored in one direction. c. Pots and pans were stacked wet. d. Staff did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to obtain an informed consent for psychotropic/psychotherapeutic (any drug that affects behavior, mood, thoughts, or perception) drugs for one of one sampled resident (Resident 39) who was prescribed Sertraline (medication used to treat depression [a persistent feeling of sadness and loss of interest]), and Divalproex (medication used to treat certain types of seizures (epilepsy) and mood disorder (a disorder manifested by severe feeling of sadness and no interest with ADLs [activity of daily living]). This deficient practice had violated Resident 39 ' s rights to be informed and choose the type of care or treatment to be received, make decisions on alternative measures the resident or responsible party preferred, which can negatively affect Resident 39 ' s quality of life. Findings: A review of the admission record indicated Resident 39 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included dementia (a group…

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 reasonable accommodations of need for resident needs and preferences for 2 out of 22 sampled residents (Resident 22 and 35) by not ensuring the overhead light cord was within resident (22 and 35) ' s reach that prevented resident 22 and 35 from having the ability to turn the light on or off as needed. This deficient practice is not in line with the resident ' s right to have adequate lighting and reasonable accommodation of needs and preferences which limits the resident's ability to see clearly and adjust the lighting to their individual needs. In addition, this deficient practice could also result in accident that results in injury to the residents. Findings: 1. A review of an admission information indicated Resident 22 was admitted to the facility on [DATE], with diagnoses that included atrial fibrillation (abnormal irregular heartbeat), rheumatoid arthritis (swelling and stiffness of joints) and Dry eye syndrome (eyes do not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide adequate lighting suitable to perform tasks that the resident chooses to perform, or the facility staff must perform to assist one of twenty-two sampled residents (Resident 48). This deficient practice violated the resident ' s right to reasonable accommodation of needs and preferences which was essential to creating and individualized, home- like environment to include adequate and comfortable lighting levels. This deficient practice could also result in resident falls or accidents in the room which could lead to injury. Comfortable light means lighting that minimizes glare and provides maximum resident control, where feasible, over the intensity, location, and direction of lighting to meet their needs or enhance independent functioning. Findings: A review of Resident 48 ' s admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included fracture of neck, right femur (thigh bone), right…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop an individualized resident-centered care plan (a care plan that prioritizes the unique health needs and desired outcomes of the resident) to meet the resident's' needs for two of 2 sampled residents (Resident 17 and Resident 187). 1. Resident 17 did not have a care plan with a measurable objective to ensure the resident is participating in activities. 2. Resident 187 was unable to attend group activity. The care plan did not indicate the reason the resident was unable to attend activities. The care plan goals indicated Resident 187 will benefit and participate in room/bedside activities: X/week. This deficient practice had the potential for the residents not to receive the appropriate interventions to achieve the goals to achieve the highest practicable mental and psychosocial (social, cultural, and environmental influences on the mind and behavior) wellbeing and improve in the quality of life. Findings: A review of Resident 17 ' s admission…

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 necessary care and services to one of three sampled residents (Resident 46) who was dependent with the staff to carry out activities of daily living (ADL) by not maintaining grooming, and good personal hygiene by not shaving her long facial hairs above the lips and under the chin. This deficient practice had the potential to negatively affect Resident 46 ' s self image, physical appearance, dignity, and quality of life. Findings: A review of Resident 46s admission record indicated the resident was admitted to the facility on [DATE] with diagnoses that included cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain), Alzheimer ' s disease (a brain disorder that slowly destroys memory, thinking skills, and eventually loose the ability to carry out the simplest tasks), and history of pneumonia (swelling of the tissue in one or both lungs, usually caused by a bacterial infection). A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide sufficient hydration to one of 2 sampled residents (Resident 22) who was not provided and offered water at bedside to maintain and promote proper hydration (process of replacing water loss in the body) and health as indicated in resident ' s care plan. This deficient practice had the potential to place the resident at risk for dehydration (a harmful reduction in the amount of water in the body) and poor nutritional outcomes. Findings: A review of Resident 22 ' s Face Sheet (Document that gives a patient ' s information such as contact details and brief medical history) indicated the facility admitted Resident 22 on 3/1/2024, with diagnoses that included proximal atrial Fibrillation (abnormal Heartbeat), Chronic constipation (Not passing stools regularly) rheumatoid arthritis (condition that causes pain and swelling and stiffness in the joints). A review of Resident 22 ' s Minimum Data Set (MDS – comprehensive assessment and care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, the facility failed to ensure a call light (a device that allows residents to signal caregivers when they are in need of help and allows caregivers to communicate with each other at a distance) was accessible while in bed for one of five sampled residents (Resident 39) who was observed with call light stuck between the left side bedrail and the bed, hanging below the bottom of the mattress. Resident 39 stated she needed assistance from the staffs because she was having difficulty putting her sweater and she was feeling cold and unable to reach the call light to call for assistance. This failure had the potential for Resident 39 not to receive assistance timely or not receive assistance with her needs or in an event of an emergency that could result in a decline in performing ADLs (activities of daily living) residents well being. Findings: A review of Resident 39 ' s admission record indicated the resident was originally admitted to the facility on [DATE] 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 failed to place fall risk identifiers for one of three sampled residents (Resident 1) in accordance with the facility ' s policy and procedure (P&P). This failure had the potential to result in repeated falls for Resident 1 who already had a history of multiple falls with injury. Findings During a review of Resident 1 ' s admission record, the admission Record indicated the resident was originally admitted to the facility on [DATE], with diagnoses that included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), hypertension (high blood pressure), hyperlipidemia (excess of fats in the blood), and atrial fibrillation (abnormal heartbeat that can lead to blood clots in the heart). During a review of Resident 1 ' s Fall Risk Assessment, dated 12/28/2022, indicated a Fall Risk Score of 16 that means Resident 1 was assessed as high risk for falls. During a review of Resident 1 ' s Minimum…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, the facility failed to ensure the call light was within reach, as indicated in the care plan for fall and dementia, and in accordance with the facility's policy for falls and call lights for one of two sampled residents (Resident 1). This failure had the potential to negatively affect Resident 1 ' s quality of life and quality of care for not being able to call for assistance if needed. Resident 1 had diagnoses that include dementia and anxiety disorder. Resident 1 was a fall risk and had a fall incident on 10/24/23. Resident 1 had been diagnosed with osteoporosis ( decrease in bone strength that can increase the risk of fractures) and had an injury of unknown origin on 11/06/23 Left Hip Fracture (Break). Resident 1 was readmitted [DATE] status post-surgery from the left hip fracture and requires maximum assist with activity of daily living (ADL). Findings: A review of Resident 1 ' s admission record indicated Resident 1 was admitted to the facility on [DATE], 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 failed to ensure one of three sampled residents, who were at risk for falls and history of multiple falls, had assigned direct care staff that were made aware of revisions to the resident ' s fall care plan by failing to: 1. Ensure Resident 1 ' s fall care plan initiated on 9/20/23 and revised on 10/21/23 was implemented to include staff visual monitoring every hour for fall precaution. 2. Include Resident 1 on the list of residents for CNA3 to monitor. 3. Orient CNA3 on Resident 1 ' s history of falls and fall interventions to be implemented. 4. Ensure CNA3 would monitor Resident 1 as part of general fall prevention and not only when out of bed and in the Activity Room. As a result, Resident 1 had a fall on 10/13/23 which resulted to an acute appearing left femoral periprosthetic fracture (a broken bone that happens around or very close to the implants [metal and plastic] of a hip replacement) and another fall, on 10/20/23 (within 7 days) which…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 2) was free from sexual abuse (non-consensual sexual contact) on 9/22/2023 around 2 PM when Resident 1 exposed his penis (the male genital organ) and grabbed Resident 2 ' s breast while in the facility ' s Activity Room as observed by Resident 3. These deficient practices resulted in Resident 2 experiencing sexual abuse and unwanted nonconsensual sexual contact from Resident 1. Resident 2, who has a diagnosis of Alzheimer ' s (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks) with dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) did not exhibit a change in behavior due to the sexual abuse but had a potential to suffer a negative psychosocial outcome such as anger, fear, anxiety, or loss of self-esteem using the reasonable person…

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 report allegations of sexual abuse from another resident to the State Agency (California Department of Public Health [CDPH]) and other officials immediately, but not later than two hours, in accordance with the facility ' s policy and procedure on Abuse Investigation and Reporting Policy and Procedure, for one of three sampled residents (Residents 3). Resident 3 and Family Member (FM 1) reported to facility staff (Receptionist [RCP]) that Resident 1 was observed exposing his penis (the male genital organ) and grabbing Resident 2 ' s breast while in the facility ' s Activity Room on 9/23/2023. This deficient practice had the potential for the facility to under report allegations of abuse, neglect, exploitation or mistreatment which could lead to failure to investigate all types of abuse in a timely manner and protect residents from abuse. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on…

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