Woods Health Services

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure medical records were complete for one of three sampled residents' (Resident 4). Resident 4's Inventory of Personal Effects (IPE) form was not signed or dated to indicate Resident 4's personal belongings were picked up by Resident 4's family when Resident 4 was discharged from the facility.This failure resulted in inaccuracy of Resident 4's IPE after Resident 4 left the facility.Findings:During a review of Resident 4's admission Record (AR), the AR indicated, Resident 4 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including chronic obstructive pulmonary disease (COPD - a long standing lung disease causing difficulty in breathing) with acute (sudden) exacerbation (flare up), and essential (primary) hypertension (HTN - high blood pressure).During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool), dated 3/7/2026, the MDS indicated Resident 4's cognitive skills (ability…

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 promptly notify the physician of a change in condition for one (1) of three (3) sampled residents (Resident 1) when Resident 1's new onset buttocks pain following a fall on 4/23/2026 was not communicated to Resident 1's primary physician.This deficient practice had the potential to delay further assessment, timely diagnostic evaluation, and timely interventions related to the resident's change in condition and possible injury.Cross reference F689 and F684During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 3/24/2026, with diagnoses including displaced bimalleolar fracture of right lower leg, subsequent encounter for closed fracture with routine healing (broken bones on both sides of the right ankle/lower leg that were out of place, currently healing normally after treatment), unspecified abnormalities of gait and mobility (difficulty walking, balancing, or moving safely), and generalized muscle weakness.During a review of Resident 1's Minimum Data Set (MDS-a resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide cardiopulmonary resuscitation (CPR, emergency lifesaving procedure, consisting of chest compressions and manual or mechanical breaths, performed when the heart stops beating or beats ineffectively and/or to restore breathing) to one of three sampled residents (Resident 3) in accordance with the facility's Policy and Procedure (P&P) titled Emergency Procedure- Cardiopulmonary Resuscitation, dated [DATE], when: 1. Rescue breaths were not provided to Resident 3 on [DATE] at 12:35 PM. 2. An artificial manual breathing unit (Ambu bag, a handheld medical device used to manually force air or oxygen into a person's lungs) and a non-rebreather oxygen mask (a medical device used in emergencies to deliver high concentrations of oxygen) were available for use in the facility's emergency cart on [DATE] 12:35 PM. These deficient practices resulted in an inadequate emergency lifesaving response for Resident 3 and placed other residents in the facility at risk…

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 provide necessary care and services to one (1) of three (3) sampled residents (Resident 1) when:A. Licensed Nurses failed to assess and accurately document Resident 1's pain status following a fall on 4/23/2026.B. Resident 1's new onset buttocks pain following a fall on 4/23/2026 was not communicated to Resident 1's primary physician.These deficient practices had the potential to result in inaccurate pain assessment, delayed recognition of worsening conditions or injury, and ineffective pain management interventions for Resident 1.Cross reference F580 and F689During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 3/24/2026, with diagnoses including displaced bimalleolar fracture of right lower leg, subsequent encounter for closed fracture with routine healing (broken bones on both sides of the right ankle/lower leg that were out of place, currently healing normally after treatment), unspecified abnormalities of gait and mobility (difficulty walking, balancing, or moving…

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 adequate safety precautions during activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) care for one (1) of three (3) sampled residents (Resident 1) by failing to ensure:A. A safe environment during post-shower care on 4/23/2026 by allowing Resident 1 to stand while the floor remained wet.B. Safe ADL care practices were implemented during post-shower care on 4/23/2026 by allowing Resident 1 to stand while clothing remained positioned at the resident's knees, creating increased instability and fall risk.C. Two (2) staff assisted Resident 1 to get up and stand from the shower chair on 4/23/2026.These deficient practices resulted in Resident 1 sustaining a fall to the floor during ADL care and experiencing pain on 4/23/2026, placing the resident at increased risk for continued pain and injury, including, head injury, fracture, and further decline in functional status.Cross reference F580 and F684During a review of Resident 1's admission Record (AR), the AR…

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 nursing staff demonstrated and maintained competency to safely provide care and services in accordance with professional standards, as evidenced by: 1. Facility did not ensue Certified Nursing Assistants (CNAs) maintained a current cardiopulmonary resuscitation ([CPR] an emergency procedure used when a person's breathing or heartbeat stops) certification while working at the facility. 2. Facility did not ensure CNAs were evaluated annually for patient care competencies and skills. 3. Facility did not ensure licensed nurses had a complete competency and evaluation checklist on file. 4. Facility did not ensure Registered Nurse (RN1) was evaluated by competent licensed nurse. 5. Facility did not ensure licensed nurses were competent during a resident emergency. These deficient practices created a risk to resident safety, delayed care, and an inappropriate emergency response. Findings: 1. During a review of Certified Nursing Assistance (CNA)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) was properly assessed and monitored upon experiencing a change in condition when:1. Resident 1's oxygen saturation level (O2 sat- a measurement of how much oxygen the blood is carrying as a percentage) was not reassessed after oxygen was administered to Resident 1 on [DATE] after Resident 1 was found unresponsive with an O2 sat of 89% (normal O2 sat level for most healthy adults is between 95% and 100%).2. Resident 1's blood pressure (BP) and respiratory/breathing rate (RR) were not assessed on [DATE] when Resident 1 was found unresponsive at 11 pm.These failures resulted in an incomplete assessment of Resident 1 while Resident 1 was experiencing a change in condition and had the potential to result in Resident 1 not receiving rescue breathing and CPR (cardiopulmonary resuscitation, emergency lifesaving procedure, consisting of chest compressions and mouth-to-mouth or mechanical breaths, performed when…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement the comprehensive person-centered care plan for one of three sampled residents (Residents 1) when Certified Nurse Assistant (CNA) 1 failed to use 2 staff persons while transferring (moving a resident from one flat surface to another) Resident 1 with an EZ Stand (a transfer-assist device) according to Resident 1's Care Plan Report (CPR), undated.This failure had the potential for Resident 1 to fall and sustain injuries while being transferred.During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on [DATE] with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), muscle wasting and atrophy (loss of muscle tissue), and dementia (a group of thinking and social symptoms that interferes with daily functioning).During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated [DATE], the MDS indicated 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 interview and record review, the facility failed to complete an annual performance review for four of four sampled Certified Nursing Assistants (CNA).This failure had the potential to result in the CNA's giving the residents improper care, making clinical errors, and causing resident injury.Findings:During a review of CNA 1's employment record, the record indicated CNA 1 was hired on 4/25/2024. CNA 1's last performance review was done on 11/4/2024. The record did not indicate a performance review was done in 2025.During a review of CNA 2's employment record, the record indicated CNA 2's last performance review was done on 12/30/2024. The record did not indicate a performance review was done in 2025.During a review of CNA 4's employment record, the record indicated CNA 4 was hired on 7/19/2007. CNA 4's last performance review was done on 12/28/2023. The record did not indicate a performance review was done in 2024 and 2025.During a review of CNA 5's employment record, the record indicated CNA 5 was hired on 10/16/2023. CNA 5's last performance review was done on 2/12/2024.…

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 on interview and record review, the facility staff failed to inform one of one sampled resident's (Resident 1) doctor of Resident 1's low blood pressure (BP - the force of blood pushing against the artery walls as the heart pumps around the body) reading on 12/4/2025 when Resident 1 was admitted to the facility.This deficient practice had the potential to lead to further complications such as dizziness, confusion, and physical injury to Resident 1.Cross Reference F689Findings:During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including atrial fibrillation (an irregular heartbeat in which the upper chambers of the heart [the atria] beat inconsistently and rapidly) and hypertension (high BP - when one's blood pushes too forcefully against the artery walls.)During a review of Resident 1's Progress Notes (PN), dated 12/4/2025, the PN indicated Resident 1 was admitted to the facility via…

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 staff failed to implement interventions to reduce the risk for falls for one of three sampled residents (Resident 1), who was at high risk for falls, when Resident 1 was admitted to the facility on [DATE] with low blood pressure (a condition in which the force of blood pushing against the artery walls is too low).This deficient practice potentially led Resident 1 to slide off Resident 1's bed onto the floor on 12/4/2025 while attempting to stand to use the urinal. This deficient practice had the potential to result in injury and a physical decline to Resident 1.Cross Reference F684Findings:During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including atrial fibrillation (an irregular heartbeat in which the upper chambers of the heart [the atria] beat inconsistently and rapidly) and hypertension (high blood pressure - when a person's blood pushes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow its own Unusual Occurrence Reporting policy, which requires that unexpected resident deaths be reported to the State Licensing Agency within 24 hours.This failure resulted in a delay of state regulatory notification, which has the potential to delay timely oversight, review, and investigation of resident safety incidents.Findings: During a review of Resident 1's admission Record (AR), the facility admitted Resident 1 on [DATE], with diagnoses including pneumonia (a lung infection), and sepsis (a life-threatening complication of an infection). During a review of Resident 1's History and Physical (H&P), dated [DATE], the H&P indicated Resident 1 had the mental capacity to make medical decisions. During a review of Resident 1's Nurses' Note, dated [DATE], the Nurses' Note indicated Resident 1 died on [DATE]. During an interview on [DATE] at 1:30PM with the Administrator, the Administrator stated the resident's death was considered an unusual…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received treatment for a left first toe fracture (break in bone) per physician's orders. This deficiency had the potential for Resident 1's injury to get worse. Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with multiple diagnoses including disorders of bone density and structure (condition where bones become weaker and more prone to fracture) and muscle wasting and atrophy (the loss of muscle mass and strength resulting in reduced physical function and mobility). During a review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 5/2/2025, the MDS indicated Resident 1 had moderately impaired cognition (ability to understand and process information) and required partial assistance (helper does less than half the effort) for personal hygiene and to walk 10 feet.…

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 a complete and accurate medical record for one of three sampled resident (Resident 1) when: a. Registered Nurse (RN) 1 failed to document Resident 1's left hip wound upon admission to the facility on 2/18/2025. b. Facility staff (in general) failed to document the description of Resident 1's left hip wound on 3/19/2025, 3/26/2025, 4/9/2025, and 4/16/2025. These failures resulted in Resident 1's medical record containing inaccurate and incomplete information. (Cross Reference F656 and F684) Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 2/18/2025 with diagnoses including acute osteomyelitis (bone infection) of the left femur (thigh bone), infection and inflammatory reaction due to internal left hip prosthesis (artificial body part), and dysphagia (difficulty swallowing foods or liquids). During a review of Resident 1's History and Physical (H&P), dated 2/19/2025, the H&P indicated Resident 1 had a healing wound on the left hip.…

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 develop and implement a comprehensive person-centered care plan for one of three sampled resident (Residents 1) by failing to ensure Resident 1's care plan's interventions included a treatment order to cover Resident 1's left hip wound. This failure had the potential result in unmet individualized needs for Resident 1 and the potential to affect the resident's physical and psychosocial well-being. (Cross Reference F684 and F842) Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 2/18/2025 with diagnoses including acute osteomyelitis (bone infection) of the left femur (thigh bone), infection and inflammatory reaction due to internal left hip prosthesis (artificial body part), and dysphagia (difficulty swallowing foods or liquids). During a review of Resident 1's History and Physical (H&P), dated 2/19/2025, the H&P indicated Resident 1 had a healing wound on the left hip. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to promote the resident/responsible party's right to be informed of and participate in treatment for one of five (Resident 29) sampled residents by failing to obtain a consent and inform Resident 29's responsible party in advance of the risks and benefits of a psychoactive (medications that affect the mind or behavior) medication, Seroquel (a medication used to treat symptoms of psychosis [a collection of symptoms that affect the mind, where there has been some loss of contact with reality]). This failure violated the responsible party's right to make an informed decision on behalf of Resident 29 regarding the use of a psychoactive medication. Findings: During a review of Resident 29's admission Record (AR), the AR indicated Resident 29 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease (a progressive disease affecting the nervous system marked by tremor [involuntary shaking or movement], muscular rigidity, and slow,…

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 irregularities identified from the Monthly Drug Regimen Review (MDRR), reported by the facility's pharmacist were acted upon for one of five sampled residents (Resident 13) by failing to: a. Ensure action was taken for the use of GI meds Famotidine and pantoprazole for January 2025 b. Ensure Resident 13's physician was informed to reconsider the use of simvastatin (medication used to treat fat in the blood) for February 2025. c. Ensure Resident 13's physician was informed to consider a gradual dose reduction for antipsychotic medication (medication to treat psychosis [loss of touch with reality] for March 25025, These deficient practices had the potential to result in unnecessary medication administration. Cross reference F758 Findings: During a review of an admission Record indicated Resident 13 was re-admitted to the facility on [DATE] with diagnoses that included dementia (a decline in mental ability severe 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 observation, interview, and record review, the facility failed to maintain infection control practices by failing to: a. Ensure enhanced barrier precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs, bacteria that have become resistant to certain antibiotics] in nursing homes) were followed and Personal Protective Equipment (PPE, gown, gloves, mask and face shield) were worn while providing care for Resident 47. b. Ensure Resident 8's nasal cannula ([NC] a device-lightweight flexible plastic tubing used to deliver supplemental oxygen, tubing ending is placed in the nostrils and is fitted over the patient's ears) did not touch the floor. c. Ensure Resident 47's NC did not touch the floor. These deficient practices had the potential to result in the transmission of infectious microorganisms and increase the risk of infection for Residents 8 and 47. Findings: a. During a review of Resident 47s admission Record (AR), the AR 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 observation, interview and record review, the facility failed to ensure a call light was within reach for one of one sampled resident (Resident 31) and failed to ensure a call light was answered timely for one of one sampled resident (Resident 30). This deficient practice had the potential to result in a delay in treatment and/or result in unmet needs for Resident 31 and Resident 30. Additional the deficient practice had the potential to result in harm to Resident 30. Findings: a. During a review of Resident 31's admission Record (AR), the AR indicated that Resident 31 was admitted to the facility on [DATE] with diagnoses that included unspecified visual loss, muscle wasting and anxiety (a feeling of worry, nervousness, or unease). During a review of Resident 31's care plan (CP) titled Sensory/perception Alterations: Visual with severely impaired vision, legally blind ., revised on 1/16/2023, the CP indicated the call light should be within reach and answered promptly as part of the facility'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 interview and record review, the facility failed to accurately code the Minimum Data Set (MDS - a standardized assessment and screening tool) related to anticoagulant (medicine that help prevent blood clots) use for one (1) of 1 sampled resident (Resident 26). This deficient practice had the potential to negatively affect Resident 26's plan of care and delivery of necessary care and services. Findings: During a review of Resident 26's admission Record (AR), the AR indicated the facility admitted Resident 26 to the facility on 6/5/2019, and re-admitted the resident on 3/1/2025, with diagnoses that included hemiplegia (paralysis that affects only one side of your body) and hemiparesis (weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing) following cerebral infarction (happens when blood flow to part of the brain is blocked, causing brain tissue to die due to lack of oxygen) affecting left non-dominant side, diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor…

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 a Minimum Data Set (MDS, a resident assessment tool) accurately reflected one of one sampled resident's (Resident 47) hospice (interdisciplinary medical caregiving approach aimed at optimizing quality of life and mitigating or reducing suffering among people with serious and often terminal illnesses expected to live six months or less, end of life) status. This deficient practice had the potential to result in unsuitable treatment and unmet needs to Resident 47. Findings: During a review of Resident 47's admission Record (AR), the AR indicated Resident 47 was admitted to the facility on [DATE] with diagnoses that included heart failure (when the heart muscle can't pump enough blood to meet the body's needs for blood and oxygen), depression (a mood disorder that may cause persistent sadness or loss of interest in activities), and anxiety disorder (persistent feeling of dread or panic that can interfere with daily life). During a review of…

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

Based on observation, interview, and record review, the facility failed to ensure that medications, their purpose, and potential side effects were explained prior to administration for one (1) of two sampled residents (Resident 19). This failure posed a risk of adverse drug reactions, decreased resident understanding and compliance, and a violation of resident rights to informed consent. Findings: During a review of Resident 19's admission Record (AR), the AR indicated the facility admitted Resident 19 on 11/18/2022, with diagnoses that included pulmonary embolism (a blood clot, often originating in a leg vein, travels to the lungs and blocks a blood vessel, potentially causing serious health issues), diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), and dementia (a progressive state of decline in mental abilities). During a review of Resident 19's History and Physical (H&P), dated 10/16/2024, the H & P indicated Resident 19 did not have the capacity to understand and make decisions. During a review of Resident 19's Minimum…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide care in accordance with professional standards of practice for one of one sampled residents (Resident 8) by failing to: a. Ensure Resident 8 received the correct amount of oxygen [colorless, odorless gas] ordered via nasal cannula ([NC] a device-lightweight flexible plastic tubing used to deliver supplemental oxygen, tubing ending is placed in the nostrils and is fitted over the patient's ears). This deficient practice resulted in incorrect oxygen administration to Resident 8 the the potential for a physical decline to Resident 8. Findings: a.During a review of Resident 8's admission Record (AR), the AR indicated Resident 8 was admitted to the facility on [DATE] with diagnoses that included urinary tract infection (UTI- infection that happen when bacteria enter the urethra, and infect the urinary tract), heart failure (when the heart muscle can't pump enough blood to meet the body's needs for blood and oxygen), and dysphagia…

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

Based on observation, interview, and record review, the facility failed to implement a physician order for floor mats to be placed on both sides of the bed to prevent injury in the event of a fall for one (1) of three sampled residents (Resident 36). This failure had the potential to result in a preventable injury, such as fractures or head trauma, due to an unprotected fall from bed, compromising resident safety and care standards. Findings: During a review of Resident 36's admission Record (AR), the AR indicated the facility admitted Resident 36 on 6/20/2023, with diagnoses that included Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), dementia (a progressive state of decline in mental abilities), and repeated falls. During a review of Resident 36's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 3/14/2025, the MDS indicated Resident 36's cognitive (the ability to think and process information) skills for daily decision making was severely impaired. The MDS indicated Resident 36 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.

Based on observation, interview, and record review, the facility failed to post the actual nursing hours for all shifts from 4/3/2025 to 4/4/2025 and failed to ensure the hours were posted in a prominent place to be readily accessible for residents and visitors. This failure had the potential to result in the residents and visitors not knowing whether there was sufficient staff to provide quality care to the residents and resulted in nurse staffing information being inaccessible to visitors. Findings: During observations on 4/1/2025 at 4 PM, 4/2/2025 at 11:51 AM, and 4/3/2025 at 12:40 PM, the staffing sheet was only posted at the nursing station. During an observation on 4/3/2025 at 2:58 PM, the staffing posting did not include total and actual hours worked per shift for licensed and unlicensed staff responsible for resident care. During an interview on 4/4/2025 at 9:15 AM with the Staffing Assistant (SA), the SA stated the only nursing staffing postings in the facility were posted at the nursing station. The SA further stated, actual hours worked per shift for licensed and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 13) who was on a psychotropic medication (medications that affect the mind, emotions, and behavior), Seroquel (used to treat certain mental/mood conditions) received a gradual dose reduction as indicated by the facility's pharmacist recommendation and the facility policy. This deficient practice had the potential to result in the resident taking psychotropic medication unnecessarily and be at risk for further harm/injury. Cross reference F756 Findings: During a review of Resident 13's admission Record, the admission Record indicated Resident 13 was re-admitted to the facility on [DATE] with diagnoses that included dementia (a decline in mental ability severe enough to interfere with daily life) with psychotic (a serious mental illness characterized by lost contact with reality) disturbances, anxiety (a feeling of worry, nervousness, or unease) and depression (causes feelings of sadness). During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to proper food storage and ensure sanitary conditions were followed by failing to: A. Ensure food past it's use-by date was not stored in one of one walk-in refrigerator (Refrigerator 1) observed in the kitchen. B. Ensure staff were completing the sanitation bucket log, ice machine log, and dish machine log daily. These deficient practices placed the residents at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages). Findings: A. During an observation on 4/1/2025 at 09:45 AM, in the kitchen, the Refrigerator 1 had 5 beef base containers stored and were labeled with a past best if used by date of 2/23/2025. During an interview on 4/1/2025 at 10:14 AM, with the dietary supervisor (DS), the DS stated the facility should ensure food in Refrigerator 1 was not stored past its best if used by [date], because this ensured food safety, prevented contamination, and complied with health regulations.…

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 accurate discharge disposition medical record documentation for one of one sample resident (Resident 50). This deficiency resulted in incomplete and potentially misleading information regarding the Resident 50's discharge status. Findings: During a review of Resident 50's admission Record (AR), the AR indicated the facility admitted Resident 50 on 2/7/2025, with diagnoses including atrial fibrillation (an irregular heartbeat that occurs when the electrical signals in the atria [the two upper chambers of the heart] fire rapidly at the same time), shortness of breath, and muscle weakness (generalized). During a review of Resident 50's Discharge Planning Review, undated, admission dated 2/7/2025, the review indicated Resident 50 requested a discharge to another long-term care center. During a review of Resident 50's History and Physical (H&P), dated 2/10/2025, the H&P indicated Resident 50 had the capacity to understand and make decisions. During a review of Resident 50's Minimum Data Set (Minimum Data Set (MDS - a…

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

Based on observation, interview and record review, the facility failed to investigate and monitor for signs and symptoms of Respiratory Syncytial Virus (RSV - is a common respiratory virus that usually causes mild, cold-like symptoms that affects infants and older adults who are more likely to develop severe RSV and need hospitalization) among healthcare personnel/healthcare workers after these healthcare workers exposed to two of two sampled residents (Residents 1 and 2) who tested positive for RSV. These deficient practices had the potential to spread RSV to other residents and staff. Findings: a. During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted the resident on 6/12/2023, with diagnoses that included hypertensive heart disease (a condition that develops when prolonged high blood pressure damages the heart muscle), chronic kidney disease (a condition where the kidneys gradually lose their ability to filter waste products and excess fluid from the blood. This can lead to a buildup of harmful substances in the body and various health…

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 its infection prevention and control program for 2 of 4 sampled residents (Residents 1 and 2) by failing to ensure hand hygiene was performed during meal pass at lunch between Resident 1 and Resident 2. These deficient practices had the potential to transmit infectious microorganisms and increase the risk of infection for Residents 1 and 2. Findings During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 11/27/2024, and re-admitted the resident on 12/12/2024, with diagnoses including left femur (thigh bone) fracture, gastrointestinal hemorrhage (any bleeding that occurs in the digestive tract, from the mouth to the anus), and muscle wasting and atrophy (loss of muscle tissue). During a review of Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 12/19/2024, the MDS indicated Resident 1's cognition (the ability to think and process…

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 accurately complete the infection monitoring form during an influenza outbreak for one of four sampled residents (Resident 3). This deficient practice had the potential for Resident 3 to not have an accurate assessment, progression, or regression of the delivery of care services. Findings: During a review of Resident 3's admission Record (AR), the AR indicated the facility admitted Resident 3 on 12/16/2024, with diagnoses including influenza (a contagious respiratory illness that affects the nose, throat, and sometimes the lungs) pneumonia (an infection/inflammation in the lungs) and respiratory failure. During a review of Resident 3's History and Physical (H&P), dated 12/18/2024, the H&P indicated Resident 3 had the capacity to understand and make decisions. During an interview and a concurrent record review on 12/27/2024 at 2:01 PM, with the Director of Nursing (DON), the Infection Monitoring Forms for the facility's influenza outbreak, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow its policies and procedures (P&P) titled, Falls Management Program, and Care Plans, Comprehensive Person-Centered, by failing to revise the care plan and implement new interventions after multiple falls for two of three sampled residents (Resident 1 and 2). This deficient practice had the potential to place Residents 1 and 2 at risk for further falls and injury. Findings: 1. During a review of Resident 1's admission Record (AR), the AR indicated the facility originally admitted Resident 1 on 5/1/2022, and most recently admitted Resident 1 on 3/12/2024, with diagnoses that included congestive heart failure (happens when the heart cannot pump enough blood to meet the body's needs), bradycardia (slow heart rate), and Parkinson's disease (a disorder that affects the nervous system and the parts of the body controlled by the nerves) without dyskinesia (uncontrolled movements of the face, arms, legs, or trunk). 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.

Based on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, Charting and Documentation, to have complete documentation for one of three sampled residents (Resident 1). This deficient practice had the potential for lack of communication between the facility staff regarding Resident 1's condition and could result in inconsistencies of care. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility originally admitted Resident 1 on 5/1/2022, and most recently admitted Resident 1 on 3/12/2024, with diagnoses that included congestive heart failure (happens when the heart cannot pump enough blood to meet the body's needs), bradycardia (slow heart rate), and Parkinson's disease (a disorder that affects the nervous system and the parts of the body controlled by the nerves) without dyskinesia (uncontrolled movements of the face, arms, legs, or trunk). During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 6/19/2024, the MDS indicated Resident 1 was…

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

Based on interview and record review, the facility failed to report a communicable disease (an illness that can spread from one person to another, or from an animal to a person, or from a surface or food) to the California Department of Public Health (CDPH) for one of three sampled residents (Resident 1) when Resident 1 tested positive for Hepatitis A virus (a highly contagious virus transmitted through ingestion of contaminated food and water or through direct contact with an infectious person). This deficient practice had the potential for a communicable disease to spread and not be properly and timely investigated. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility originally admitted Resident 1 on 5/1/2022, and most recently admitted Resident 1 on 3/12/2024, with diagnoses that included congestive heart failure (happens when the heart cannot pump enough blood to meet the body's needs), bradycardia (slow heart rate), and Parkinson's disease (a disorder that affects the nervous system and the parts of the body controlled by the nerves)…

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 infection control practices to reduce and/or prevent the spread of Covid-19 (Coronavirus, a highly contagious respiratory disease caused by SARS-CoV-2 virus that spreads from person to person and can cause mild to severe respiratory illness) in accordance with the facility's policies and procedures (P&Ps) when: a. One of one housekeeper (Housekeeper, HK) entered a Covid-19 isolation room without the required face shield, or goggles as indicated on the sign posted outside Resident 1's room. b. Three of three tumbler cups belonging to facility staff were left on the handrail in the red zone (a cohorting [grouping patients infected or colonized with the same infectious agent] for residents who tested positive for Covid-19). These deficient practices had the potential to result in the spread of Covid-19 infection throughout the facility residents and/or staff. Findings: During a review of Resident 1's admission Record (AR), the AR…

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 answer the call lights in a timely manner for seven of 16 sampled residents (Residents 2, 15, 30, 31, 148, 149, and 150). This failure resulted in Residents 2, 15, 30, 31, 148, 149, and 150 feel frustrated and had the potential for the residents to experience a decline in psychosocial well-being. Cross reference F725 Findings: During a review of Resident 2's admission Record (AR) the AR indicated Resident 2 was admitted to the facility on [DATE] with multiple diagnoses including congestive heart failure (CHF, the heart doesn't pump blood as well as it should), dysphagia (difficulty swallowing foods or liquids), and hypotension (low blood pressure). During a review of Resident 2's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 2/28/24, the MDS indicated Resident 2 had no impairment in cognitive skills (the ability to make daily decisions). The MDS indicated Resident 2 was dependent on staff for toileting,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure resident-centered comprehensive care plans (CP, provides direction on the type of nursing care an individual needs) for three of three sampled residents (Resident 16, 25 and 11) were developed in accordance with the facility's policy and procedure (P&P). a. For Resident 16, the facility failed to develop a CP to address the use of Depakote Sprinkles medication (medication used to treat mental/ mood conditions). b. For Resident 25, the facility failed to individualize the CP related to Resident 25's nutritional weight goals and interventions related to difficulty chewing. c. For Resident 11, the CP related to risk for altered fluid balance did not have measurable objectives and timeframe. This failure had the potential for Residents 16, 25, and 11 to not receive the necessary care and services to achieve their optimal level of functioning. Findings: a. During a review of Resident 16's admission Record, the AR indicated Resident 16 was admitted to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 46) received treatment and care in accordance with professional standards of practice by failing to follow physician's order in the administration of Resident 46's antihypertensive medications (medications to treat high blood pressure [BP]). These deficient practices had the potential to result in harmful increase or decrease of Resident 46's blood pressure compromising the resident's health and safety. Findings: During a review of Resident 46's admission Record (AR), the AR indicated Resident 46 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including essential (primary) hypertension (high blood pressure) and unspecified atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). During a review of Resident 46's History and Physical Examination (H&P), dated 1/26/24, the H&P indicated Resident 46 had multiple past medical history…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide sufficient staffing resulting in toileting and/or incontinence care were not being provided in a timely manner for seven of 16 sampled residents (Residents 2, 15, 30, 31, 148, 149, and 150). This failure had the potential to result in Residents 2, 15, 30, 31, 148, 149, and 150 to experience skin breakdown and/or placing the residents at risk of experiencing a urinary tract infection (UTI, an infection in any part of the urinary system, including the kidneys, bladder, or urethra). (Cross Reference F550) Findings: During a review of Resident 2's admission Record (AR) the AR indicated Resident 2 was admitted to the facility on [DATE] with multiple diagnoses including congestive heart failure (CHF, the heart doesn't pump blood as well as it should), dysphagia (difficulty swallowing foods or liquids), and hypotension (low blood pressure). During a review of Resident 2's Minimum Data Set (MDS, a standardized 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.

Based on observation, interview and record review, the facility failed to follow safe and proper food storage and preparation practices in one of one facility kitchen, in accordance with professional standards for food service safety and the facility's policies and procedures (P&P) by failing to ensure: a. Food items were labeled/dated in the kitchen. b. Cold foods were held at 41 degrees Fahrenheit (F, a unit of measurement used to measure temperature) or lower. These failures had the potential for food borne illness (illness caused by the ingestion of contaminated food or beverage) and/or affect the quality and palatability of food for the residents. Findings: During a concurrent observation and interview on 3/26/24 at 8:16 a.m. with Utility Worker (UW) 1, in the initial tour of the kitchen, the following were observed: 1. One unlabeled/undated used 18 oz (ounces, a unit of weight) jar of peanut butter on the food preparation counter. 2. One tray of 18 unlabeled/undated individual servings of chocolate pudding covered in plastic, inside the Walk-in Refrigerator. 3. One tray 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 standard infection control practices in accordance with the facility's Policies and Procedures (P&P) by failing to: a. Safely and hygienically store personal toiletries and belongings for two of two sampled residents (Residents 9 and 98) b. Establish a surveillance plan to monitor or track infections in the facility in accordance with the facility's policy and procedure titled Infection Prevention and Control Program. These failures had the potential to result in cross contamination and/or spread of infection to the residents and staff. Findings: a.1. During a review of Resident 9's admission Record (AR), the AR indicated Resident 9 was initially admitted to the facility on [DATE] and last readmitted on [DATE] with diagnoses including myocardial infarction (heart attack, a medical emergency when the heart muscle begins to die because it isn't getting enough blood flow), type 2 diabetes mellitus (high levels of sugar in the blood)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the call light (a device used by a resident to signal the need for assistance) was within reach for one of one sampled resident (Resident 28), as indicated in Resident 28's care plans (CP-provides direction on the type of care an individual needs) titled Risk for Falls, The Resident Had Communication Problem and Resident has anxiety manifested by screaming and yelling daily for help with her stuff animals. This failure had the potential to result in Resident 28's needs not met in a timely manner and/or Resident 28 to experience harm if Resident 28 was unable to alert staff during an emergency. Findings: During a review of Resident 28's admission Record (AR), the AR indicated, Resident 28 was admitted to the facility on [DATE] with diagnoses including muscle weakness (generalized), unspecified glaucoma (a group of eye diseases that can cause vision loss and blindness) and Alzheimer's disease (a brain disorder that slowly destroys…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 9) had directions/instructions regarding treatment requests and/or wishes in the event of a medical emergency (any serious illness or condition that poses an immediate risk ) as indicated in the facility's Policy and Procedure (P&P) and Resident 9's care plan (CP- provides direction on the type of care an individual needs) titled Resident Request Code status of Full Code (all treatment provided). This failure had the potential for Resident 9 to receive inappropriate or medically unnecessary care, treatment and/or services. Findings: During a review of Resident 9's admission Record (AR), the AR indicated Resident 9 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including subsequent non-ST elevation (NSTEMI) myocardial infarction (heart attack, a medical emergency when heart muscle begins to die due to inadequate blood flow), type 2 diabetes mellitus (high levels 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 ensure one of one sampled resident's (Resident 35) Minimum Data Set (MDS, a standardized assessment and care screening tool) was completed accurately. This failure could potentially result in Resident 35 receiving inappropriate care and services based on Resident 35's preferences and goals of care, functional and health status, and strengths and needs. Findings: During a review of Resident 35's admission Record (AR), the AR indicated Resident 35 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including 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), unspecified, muscle weakness (generalized) and essential (primary) hypertension (high blood pressure). During a review of Resident 35's History and Physical (H&P) dated 4/28/23, the H&P indicated Resident 35 had the capacity to understand 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 one sampled resident (Resident 40) was free of accident (any unexpected or unintentional incident) hazards by failing to maintain Resident 40's bed in a low position. Resident 40 had multiple history of falls (unintentionally coming to rest on the ground, floor, or other lower level). This deficient practice placed Resident 40 at risk for further falls. Findings: During a review of Resident 40's admission Record (AR), the AR indicated, Resident 40 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (also known as a stroke, refers to damage to tissues in the brain), unspecified abnormalities of gait (how a person walks) and mobility (the ability to move or be moved freely and easily), muscle weakness and dementia (impaired ability to remember, think, or make decisions that interferes with everyday activities). During a review of Resident 40's History and Physical Examination (H&P) dated 10/1/23,…

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 observation, interview and record review, the facility failed to follow the physician's order to check the colostomy site ever shift to make sure it was not leaking and change the leaky colostomy bag in a timely manner for one of one sampled resident (Resident 5), who required colostomy (surgery to create an opening called a stoma. The opening creates a passage from the large intestine to the outside of your body) care and services. These failures had the potential for Resident 5's emotional well-being to be affected and had the potential to develop excoriation/breakdown to the skin surrounding the ostomy (or stoma, an artificial opening in the body, created during an operation such as a colostomy or ileostomy). Findings: During a review of Resident 5's admission Record (AR) the AR indicated Resident 5 was admitted to the facility on [DATE] with multiple diagnoses including myocardial infarction (heart attack, a blockage of blood flow to the heart muscle), colostomy, and hypertension (high blood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 10), received oxygen (O2 [a colorless, odorless, tasteless gas essential for living]) therapy consistent with professional standards of practice and in accordance with the physician's order. This failure resulted in Resident 10 to receive inaccurate oxygen supply and could potentially compromise Resident 10's medical condition. Findings: During a review of Resident 10's admission Record (AR), the AR indicated Resident 10 was admitted to the facility on [DATE] with diagnoses including heart failure (condition when the heart is unable to pump sufficiently to maintain blood flow to meet the body's needs), unspecified dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and shortness of breath. During a review of Resident 10's Order Summary Report (OSR), the ORS indicated an order on 11/28/22 for continuous O2 at three liters through…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of five sampled residents was free from unnecessary psychotropic (medicines that alter chemical levels in the brain which impact mood and behavior) medication (Resident 30). Resident 30's order for Lorazepam (medication to treat anxiety [an unpleasant state of inner turmoil and fear]) did not have an end date within 14 days from the time it was ordered. This failure had the potential for Resident 30 to receive unnecessary psychotropic medication that could result in adverse consequences for the resident. Findings: During a review of Resident 30's admission Record (AR), the AR indicated Resident 30 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), dementia (the loss of the ability to think, remember, reason to levels that affect daily life…

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

Based on interview and record review, the facility failed to ensure one of one facility's Infection Preventionist (IP- a nurse who helps prevent and identify the spread of infectious disease in the healthcare environment) completed a specialized training in infection prevention and control as indicated in the facility's job description of the Infection Preventionist. This failure had the potential for lack of oversight of the facility's infection control practices by the IP. Findings: During an interview on 3/28/2024 at 11:23 a.m. with the IP, IP stated IP has not completed the modules required for IP certification and was currently on module five of 24. During an interview on 3/28/2024 at 11:23 a.m. with the Director of Nursing (DON), the DON stated IP was still in training and DON was helping to complete IP duties while IP was completing the modules for certification. When asked if the facility currently had a certified IP, the DON stated, No, there's nothing official. During a review of the facility's job description for IP titled, Supervisor Position Description (SPD), dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an allegation of verbal abuse to one of five sampled resident (Resident 2) to the California Department of Public Health (Department) , Ombudsman (an official appointed to investigate individuals' complaints against maladministration), and to the local law enforcement, within two hours, inaccordance with the facility's policy and procedures (P&P). This failure had the potential for Resident 2 to be at risk of further verbal abuse. Findings: During a review of Resident 2's, admission Record, dated 8/22/23, indicated, Resident 2 was admitted to the facility on [DATE], with multiple diagnoses including compartment syndrome (a painful and dangerous condition caused by pressure buildup from internal bleeding or swelling of tissues), muscle wasting and atrophy (loss of muscle tissue), and presence of cardiac pacemaker (a device used to control an irregular heart rhythm). During a review of Resident 2's, Minimum Data Set, (MDS, a standardized…

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.