Freedom Village Healthcare Center

Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the antibiotics were not prescribed to one of 12 final sampled residents (Resident 53) and one nonsampled resident (Resident 31) who did not meet McGeer's criteria in the surveillance log. * The facility failed to address the use of antibiotics when Resident 31 and 53's condition did not meet McGeer's criteria for true infection. This failure had the potential for the antibiotics to be used when it was not necessary and could result in the development of antibiotic-resistant bacteria.Findings: Review of the facility's P&P titled Antibiotic Stewardship- Review and Surveillance dated 11/16/24, showed as a part of the facility Antibiotic Stewardship Program, all clinical infections treated with antibiotics will undergo review by the Infection Preventionist, or designee. The IP, or designee will review the antibiotic utilization as part of the antibiotic stewardship program and identify specific situation that are not consistent with appropriate use of antibiotics.…

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, medical record review, and facility P&P review, the facility failed to ensure the education on the risks and benefits of the vaccinations were reviewed with the resident and/or resident representative for eight of 11 residents (Residents 5, 6, 7, 27, 39, 49, 51 and 54) reviewed for immunization. * The facility failed to ensure Residents 5, 27, 49, 51, and 54 were provided education on the risk and benefits when the residents declined pneumococcal vaccination. * The facility failed to ensure Residents 6 and 39 and/or their representative was offered the pneumococcal vaccine and were provided with education on the risk and benefits of pneumococcal vaccination. * The facility failed to ensure Resident 7 received education on the risk and benefits when resident declined the influenza vaccination. These failures had the potential for the residents and/or their representatives not being informed of influenza and pneumococcal vaccine, the benefits and risks of influenza and pneumococcal vaccination…

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, medical record review, and facility P&P review, the facility failed to ensure two of 11 Residents (final sampled residents, Residents 7 and 27) reviewed for immunization were offered the COVID-19 seasonal vaccine. This failure posed the residents at risk for increased risk for infection and transmission of COVID-19.Findings: Review of the facility's P&P titled Immunization dated 11/16/24, showed the facility is to offer Influenza, Pneumococcal and COVD-19 Vaccine to residents and staff, in accordance with CDC, CDPH, CAL-OSHA regulations, and recommendations to reduce mortality and morbidity. Under the section procedure showed facility will offer Influenza, Pneumococcal and COVID- 19 vaccines to residents, staff, as scheduled and as needed. Further review of the P&P showed the residents and staff will be informed regarding the risk and benefits and potential side effects associated with the vaccine. 1. Medical record review for Resident 7 was initiated on 11/21/25. Resident 7 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, medical record review, and facility P&P review, the facility failed to ensure one of four sampled residents (Resident 3) received the appropriate services needed to maintain optimal nutritional status. * The facility failed to timely notify Resident 3's physician of the RD recommendations when Resident 3 had a weight loss of 6 pounds in six days. This failure had the potential for the resident to not receive the necessary care and intervention timely to maintain the resident's nutrition status and/or prevent further weight loss.Findings: Review of the facility's P&P titled Weight Management (undated) showed the residents' weights are monitored for undesirable or unintended weight loss or gain. Undesirable weight change is evaluated by the treatment team whether or not the criteria for significant weight change has been met. The physician and multidisciplinary team identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to follow the abuse protocol during the facility investigation period for one of two sampled residents (Resident 1). * The facility failed to suspend CNAs 2 and 3 from work when Resident 1 reported an allegation of physical abuse against these two CNAs on 11/10/24. This failure had the potential to place Resident 1 and other residents at risk of not being protected against the alleged abusers. Findings: Review of the facility's P&P titled Abuse Policy and Procedure revised 3/1/24, showed during and after the investigation, the residents will be protected from the alleged harm through the following methods: - staff will closely and frequently supervise the resident, and - if a staff member is accused or suspected of abuse, that staff member will be suspended pending the completion of the investigation. On 11/12/24, the CDPH, Licensing and Certification Program received a report from the facility regarding Resident 1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to provide the necessary care and services to ensure one of two sampled residents (Resident 1) attained and/or maintained her highest practicable physical well-being. * The facility failed to monitor Resident 1's safety and psychosocial wellbeing and developed a care plan after Resident 1 had reported an abuse allegation on 11/10/24. This failure had the potential for Resident 1 not to receive the necessary care and services. Findings: On 11/12/24, the CDPH, Licensing and Certification Program received a report from the facility regarding Resident 1's allegation of physical abuse by CNAs 2 and 3 on 11/10/24. Medical record review for Resident 1 was initiated on 11/26/24. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's Progress Note dated 11/10/24, showed Resident 1 alleged two CNAs were changing her diaper and being rough with care. The note also showed the CNAs were laughing at her. Further review of Resident 1'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 observation, interview, and facility document review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen when: * The facility failed to ensure the kitchen utensils and equipment were stored or kept in sanitary conditions. * The facility failed to ensure the kitchen equipment were cleaned properly. * The facility failed to ensure a juice machine had an air gap for back flow prevention. These failures had the potential to pose the risk for exposure to food-borne illnesses in a medically vulnerable population of 42 residents received food prepared in the kitchen. Findings: Review of the facility's matrix showed 42 residents consumed food prepared in the facility's kitchen. 1. According to the USDA Food Code 2022, Section 4-101.11, Multiuse, Characteristics, for materials that are used in the construction of utensils and food contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be safe, durable, corrosion-resistant,…

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, medical record review, and facility P&P review, the facility failed to ensure whether it was safe to self-administer the medications for one of 14 final sampled residents (Resident 24). * Resident 24 was observed to have two Voltaren (topical pain medication) gel tubes at bedside. Resident 24 did not have the physician's order or care plan problem addressing the self-administration of medications. This failure had the potential for Resident 24 to administer the medications inaccurately. Findings: Review of the facility's P&P titled Self-Administration of Medications revised 6/5/24, showed the facility should comply with facility policy, applicable law, and the State Operations Manual with respect to resident self-administration of medications. Facility, in conjunction, with the interdisciplinary care team, should assess and determine, with respect to each resident, whether self-administration of medications is safe and clinically appropriate, based on the resident's functionality…

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, medical record review, and facility P&P, the facility failed to ensure the advance directive information was documented and/or the information on how to formulate an advance directive was offered to three of 14 final sampled residents (Residents 22, 24, and 25). * The facility failed to ensure the copies of the advance directives were obtained and placed in the medical records for Residents 22 and 24. * The facility failed to ensure the POLST for Resident 25 was updated to show the advance directive was formulated. These failures had the potential for the facility to provide the treatments and services against the residents' wishes. Findings: Review of the facility's P&P titled Advance Directive revised 11/16/23, showed the following: - Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment to formulate an advance directive if he or she chooses to do so; - Information about whether or not the resident has…

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 the Notice of Medicare Non-Coverage (NOMNOC) after the termination Medicare Part A services for two nonsampled residents (Resident 45 and 47). This failure had the potential for violating the residents' rights to be informed of changes for coverage. Findings: 1. Review of Resident 45's admission Record showed the resident was admitted to the facility on [DATE], and the last covered day of Medicare Part A Services was on 8/3/24. Review of Resident 45's SNF Beneficiary Protection Notification Review dated 5/17/24, showed the resident's representative was notified regarding the resident's last covered Medicare day. However, the representative was provided copy of the CMS 20052 SNF Beneficiary Protection Notification Review as the ABN (Advance Beneficiary Notification). 2. Review of Resident 47's admission Record showed the resident was admitted to the facility on [DATE] and readmitted on [DATE]; and the last covered day of Medicare Part A Services…

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, medical record review, and facility document review, the facility failed to ensure the staff implemented two-person assist for transfers one of two final sampled residents (Resident 18) as per the plan of care, resulting the right ankle fracture treated with the right ankle splint. This failure had the potential to negatively impact the resident's well-being. Findings: Medical record review of Resident 18 was initiated on 10/21/24. Resident 18 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 18's quarterly MDS dated [DATE], showed under section GG (Functional Abilities and Goal), sit to lying, sit to stand, chair/bed to chair transfer was coded as substantial or maximal assistance. Review of Resident 18's care plan dated 9/5/24, showed a problem of activity daily living self-care performance deficits related to impaired mobility as manifested by having generalized weakness/deconditioning/debility. The interventions included to require two persons assist for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the timely intervention for one of three final sampled residents (Resident 22) reviewed for weight loss. * Resident 22 experienced a 5.32% weight loss in one month. There was no assessment from nutritional services, RD intervention, care plan, and notification to the MD and family regarding the weight loss. This failure had the potential to result in continued nutritional decline and negative outcomes. Findings: Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.18.11 dated 10/2023 showed if a resident is losing a significant amount of weight, the facility should not wait for the 30- or 180-day timeframe to address the problem. Weight changes of 5% in 1 month, 7.5% in 3 months, or 10% in 6 months should prompt a thorough assessment of the resident's nutritional status. Review the facility's P&P titled Weight Management Guidelines revised 2/2022 showed a weight…

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, medical record review, facility document review, and facility P&P review, the facility failed to provide the pharmaceutical services to ensure the accurate reconciliation and disposal of medications. * The facility failed to ensure the count performed for all controlled medications in the Omnicell (automatic drug delivery system) as per the facility's P&P. This failure posed the risk for diversion of medications. Findings: Review of the facility's P&P titled Automatic Drug Delivery Systems (ADDS) CA- Omnicare revised 2022 showed the following: - The Pharmacy tracks the AADS and generates complete and accurate user records of all transactions including all medications and other inventory added to or removed from the ADDS. - Authorized facility shall count each controlled substance and verify their count against the count according to the ADDS system. - The two authorized facility stall will each sign the ADDS daily temperature and cycle count log after the cycle count is completed. On 10/23/24 at 1620 hours, and interview was conducted with Pharmacy…

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, medical record review, and facility P&P review, the facility failed to ensure one nonsampled resident (Resident 12) was properly monitored for the stool softener medications. This failure had the potential to negatively impact the resident's health condition. Findings: Review of the facility's P&P titled Medication Administration revised 11/16/23, showed the following: - The facility policy regarding medication administration in accordance with Applicable law and the State Operations Manual when administering medications. - The licensed nurse should confirm the MAR reflects the most recent medication order. Medical record review for Resident 12 was initiated on 10/21/24. Resident was admitted to the facility on [DATE]. Review of Resident 12's Order Summary Report dated 9/29/24, showed Colace 100 mg (stool softener) one capsule by mouth two times a day for bowel management and to hold for loose stool. On 10/22/24 at 0916 hours, a medication administration observation of Resident 12 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of five final sampled residents (Resident 25) reviewed for unnecessary medications was free from the unnecessary psychotropic medications (medication that affects the mind, emotions, and behavior). This failure had the potential for Resident 25 to have adverse complications from the medication. Findings: Review of the facility's P&P titled Antipsychotic Medication and Informed Consent Policy updated June 2024 showed antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavior symptoms have been identified and addressed. The policy interpretation and implementation include among others the following: - The attending physician and other staff will gather and document information to clarify a resident's behavior, mood function, medical condition,…

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, medical record review, facility document review, and facility P&P review, the facility failed ensure proper storage and label of medications in Medication Cart 1 and medication storage room when: * Resident 7's eye drop medication in Medication Cart 1 was not kept in the refrigerator as per the medication instruction. * Resident 22's cough medication was stored with the topical ointment medication in Medication Cart 1. * Resident 686's inhalation medication in Medication Cart 1 was not labeled with an opened date as per the facility's policy . * The bottom drawer of Medication Cart 1 was not kept clean and free from spill residue. * The expired medication was stored in the medication storage room. In addtion, the licensed nurse left the medications for Resident 27 unattended while performed other tasks. These failures had the potential for the medications misuse, medication ineffectiveness, and potential exposure to harmful pathogens (bacteria, viruses, fungi) from expired…

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

Based on interview and facility document review, the facility failed to ensure the DSS who was responsible to oversee the satellite kitchen which produced food for the skilled nursing facility was qualified in managing the day-to-day functions of the food services department. This failure had the potential to negatively affect the health and well-being of 42 residents who received the food prepared in the kitchen. Findings: Review of the facility's matrix showed 42 residents who consumed food prepared in the kitchen. According to the California Code, Health, and Safety Code - HSC § 1265.4, a licensed health facility shall employ a full-time, part-time, or consulting dietitian. A health facility that employs a registered dietitian less than full time, shall also employ a full-time dietetic services supervisor who meets the requirements of subdivision (b) to supervise dietetic service operations. On 10/23/24 at 0802 hours, an interview was conducted with the DSS. The DSS stated she was responsible to manage the SNF satellite kitchen. The DSS stated the food for the SNF residents was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility document review, the facility failed to ensure the food allergy item was not served to one of 14 final sampled Residents (Resident 27). This failure had the potential for the resident's medical complication. Findings: Medical record review of Resident 27 was initiated on 10/21/24. Resident 27 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 27 Dietary Communication dated 4/12/24, showed the resident had allergies to cucumber. On 10/21/24 at 1210 hours, Resident 27 was observed eating his lunch independently and was served cucumber in his main plate. On 10/21/24 at 1230 hours, an interview and concurrent diet card review was conducted with the Dietary Service Supervisor. The DSS was asked if the resident had allergies to cucumber. The DSS stated yes and asked why the resident was served with the cucumber. The DSS stated, I will replace it now. The DSS verified the findings. On 10/24/24 at 1457 hours, an interview was conducted with…

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, facility document review, and facility P&P review, the facility failed to ensure the education was provided to the staff and family/visitors on safe food handling of outside food. This failure had the potential to cause foodborne illnesses to the medically vulnerable resident population who consumed food brought from outside sources. Findings: Review of CMS S&C-09-39 dated 5/29/09, showed the residents have the right to choose to accept food from visitors, family, friends, or other guests according to their rights to make choices. The CMS guideline further showed the facility has the responsibility under the food safety regulation to help the visitors to understand safe food handling practices such as not holding or transporting foods containing perishable ingredients at temperatures above 41 degrees Fahrenheit. Review of the facility's P&P titled Foods Brought by Family/Visitors revised 11/16/21, showed the food brought by the visitors and family is permitted. The facility staff will strive to balance resident choice and a homelike environment with the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for one of 14 final sampled residents (Resident 22) reviewed for hospice services. * The facility failed to ensure Resident 22 received hospice aide visit one time per week as ordered by the physician. * The facility failed to ensure the hospice log showed documentation regarding the CHHA visit. * The facility failed to ensure the hospice RN was included in Resident 22's Care Conference/Care Plan Meeting on 9/27/24. These failures had the potential for not providing necessary care and services to the resident recievieng hospice services. Findings: Review of the facility's P&P titled Hospice Services revised 11/16/24, showed the following: - Hospice providers who contract with this facility are held responsible for meeting the same professional standards and timelines of service as any contracted individual or agency associated with the facility. - In general, it is the responsibility…

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, medical record review, and facility documentation review, the facility failed to ensure the QA committee identified and developed action plans to address the focused areas from the last recertification survey. The QA committee failed to have documented evidence to show they identified and developed action plan to correct the identified concern of the respiratory care and medication storage. This failure had the potential to result in residents at risk for possible infection and causing adverse side effects for expired medication. Findings: Review of the facility's previous recertification survey completed on [DATE], showed the following deficient practices were cited: respiratory care (F695) and medication storage (F761). These deficient practices were the repeated deficient practices cited during this Recertification Survey. During the QAA interview with the Administrator and DON on [DATE] at 1320 hours, the DON was asked how the QAA committee identified current and ongoing…

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, medical record review, facility document review, and facility P&P review, the facility failed to implement the safe and sanitary environment to help prevent the development and transmission of infection when: * The facility failed to maintain the accurate infection surveillance program for September and October 2024. * The facility failed to ensure the infection control practices were implemented in the facility's laundry room. * The facility failed to ensure the licensed nurse (LVN 1) performed hand hygiene in between changing gloves during the medication administration observation for Resident 27. * The facility failed to ensure Foley catheter care for Resident 686 was done in the safe and sanitary manner. These failures posed the risk for not identifying the residents' infections and thereby, preventing the implementation of interventions to control the potential transmission of communicable diseases to other residents in the facility. In addition, these failures posed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, facility document, and facility P&P review, the facility failed to implement the antibiotic stewardship program. * The facility failed to ensure the appropriate use of antibiotics for one final sampled resident (Resident 25) and two nonsampled residents (Residents 9 and 20). This failure had the potential for inappropriate use and increased risk of drug resistant organisms. Findings: According to the CDC, the antibiotics are among the most frequently prescribed medications in nursing homes, with up to 70% of residents in a nursing home receiving one or more courses of systemic antibiotics over a year. Studies have shown that 40-75% of antibiotics prescribed in nursing homes may be unnecessary or inappropriate. Harms from antibiotic overuse are significant for the frail and older adults receiving care in nursing homes. These harms include risk of serious diarrheal infections from Clostridium difficile, increased adverse drug events and drug interactions, and colonization and/or infection with…

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, medical record review, and the facility P&P review, the facility failed to ensure two of 14 final sampled residents (Residents 4 and 25) were offered the influenza vaccine (vaccine given to protect the resident from influenza disease) and pneumococcal vaccine (a vaccine given to protect the resident from pneumococcal disease) when the residents were eligible to receive in accordance with the current CDC's guidelines and recommendations. This posed the risk of Residents 4 and 25 acquiring influenza and pneumonia. Findings: Review of the facility's P&P titled Immunization revised 11/16/23, showed immunization policy is to offer influenza and pneumococcal to residents and staff, in accordance with CDC and CDPH regulations and recommendations to reduce mortality and morbidity. Under the Procedure section, the residents and staff will be informed regarding the risks and benefits and potential side effects associated with the vaccine. 1. Medical record review for Resident 4 was initiated 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.

Based on interview, facility document review, and facility' P&P review, the facility failed to maintain the safe operating conditions. * The facility failed to maintain the essential temperature logs for the safe operating conditions of the Omnicell Anatomic Drug Dispensing system. This failure had the potential for the equipment to not function in the way intended, which could negatively affect the residents' medications. Findings: Review of the facility's P&P titled Storage and Expiration Dating of Medications, Biologicals, Syringes, and Needles revised 8/01/24, showed the facility should ensure that medications and biologicals are stored at their appropriate temperatures according to the United States Pharmacopeia (USP) guidelines for temperature ranges and manufacturer guidance. -Facility should monitor the temperature of medication storage areas at least once a day. Review of the facility's P&P titled Automated Drug Delivery System (ADDS) CA-Omnicare revised 2020 showed the following: -The facility shall maintain the ADDS Daily Temperature and Cycle Count Log. -The two…

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 facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. * The facility failed to ensure the expired food items in the walk-in refrigerator and dry storage area were discarded. * The facility failed to ensure the labeling and dating of foods in the kitchen and refrigerator used for the residents' food brought in by the visitors were proper. * The facility failed to ensure the kitchen equipment was clean. * The facility failed to ensure the resident dishware and utensils had a smooth cleanable surface. * The facility failed to ensure the sanitizer test strips had not expired. * The facility failed to ensure the backflow prevention of one air gap was properly maintained. These failures had the potential to cause the foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen. Findings: Review of the CMS 672 Resident Census and Conditions of Residents completed by the facility dated 2/7/23, showed 32 of 32 residents in the facility received food prepared 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility P&P review, and facility document review, the facility failed to maintain the infection control program designed to provide the safe environment and reduce the risk of development of illnesses and transmission of diseases. * The facility failed to show documentation of the Legionella (a bacteria that can cause a serious type of lung infection) facility risk assessment and testing protocols. * The facility failed to implement proper hand hygiene and changing gloves during wound care. * The facility failed to ensure a confirmed COVID-19 case was assessed every four hours for respiratory rates, temperatures, and oxygen saturation levels as per the facility's P&P for Resident 25. * LVN 2 failed to disinfect the self-sealing stopper top of the insulin (medication to lower blood sugar) vial prior to withdrawing the medication. This posed a risk for increased infection. These failures had the potential to result in the transmission of infection to a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure a quarterly care conference was conducted for one of 14 final sampled residents (Resident 14). * Resident 14's last quarterly care conference was conducted on 9/20/22. The residents' care conferences were scheduled on a quarterly basis. However, there was no documentation of any other care conferences conducted for Resident 14 after 9/20/22. This posed the risk of violating the rights of Resident 14 and/or responsible party to participate in choosing the treatment options and making the decisions in care planning. Findings: Review of the facility's P&P titled Care Plan Meetings dated 11/2022 showed the Social Worker will schedule the care plan meetings. The resident, resident's family, and/or resident's legal representative/guardian or surrogate are encouraged to attend the scheduled quarterly care plan meetings. Medical record review for Resident 14 was initiated on 2/8/23. Resident 14 was admitted 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, medical record review and facility P&P review, the facility failed to ensure one nonsampled resident (Resident 736) who could not safely self-administer medications had the medication at the bedside. This failure had the potential for Resident 736 to administer medications inaccurately. Findings: Review of the facility's P&P titled Omnicare 2.1 Self Administering Medications revised 5/2010 showed the facility, in conjunction with the Interdisciplinary Care Team, should assess and determine, with respect to each resident, whether self-administration of medications is safe and appropriate. On 2/7/23 at 0949 hours, two packets of unopened hydrocortisone cream 1% (a medicated cream used to reduce inflammation of the skin) were seen on the bedside table of Resident 736. When asked what the medication cream was for, Resident 736 stated she did not know why it was there. On 2/7/23 at 1014 hours, a concurrent interview and observation was conducted with LVN 1. When asked about the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility document review, the facility failed to ensure the Long-Term Care Ombudsman (a person who routinely visits the facility and advocated for the residents) was notified of the discharge for one of three closed record sampled residents (Resident 28). This failure had the potential of not providing Resident 74 with access to an advocate who could inform them of their options and rights related to discharge. Findings: Closed medical record review for Resident 28 was initiated on 2/9/23. Resident 28 was admitted to the facility on [DATE], and discharged on 2/1/23. Review of the facility's document titled Notice of Transfer and Discharge with effective discharge date of 2/1/23, failed to show the State Long-Term Care Ombudsman was notified of Resident 28's discharge to home. On 2/9/23 at 1245 hours, an interview and concurrent facility document review was conducted with the SSD. The SSD was asked if the facility had notified the Long-Term Care Ombudsman of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility document review, the facility failed to provide an individualized and ongoing activity program to meet the needs and interests of one of 14 final sampled residents (Resident 2) and one nonsampled resident (Resident 11). * The facility failed to provide activities for Residents 2 and 11 to meet the resident's identified interests. The facility failed to ensure the TV remote controls were provided for Residents 2 and 11. This had the potential for the residents to experience feelings of social isolation and frustration. Findings: 1. On 2/7/23 at 0948 hours, Resident 2 was observed in bed and awake. There was no in-room sensory stimulation observed. The TV was observed turned off. On 2/8/23 at 0853 hours, Resident 2 was observed in bed and awake. Resident 2 was observed staring at the window. There was no in-room sensory stimulation observed. The TV was observed turned off. When asked if she wanted to watch TV, Resident 2 nodded her head and said yes. On 2/8/23 at 0856…

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 medical record review, the facility failed to provide the necessary care and services to ensure one of 14 final sampled residents (Resident 10) on hospice services attained and maintained their highest practicable well-being. * The facility failed to communicate with the hospice agency regarding the RN/ LVN and CHHA visitation when Resident 10 was in isolation for Covid-19. This had the potential of a delay in hospice care regarding changes in Resident 10's condition. Findings: Medical record review for Resident 10 was initiated on 2/7/23. Resident 10 was admitted to the facility on [DATE]. Review of the Order Summary Report showed a physician's order dated 7/20/22, for Resident 10 to be admitted to hospice services under routine level of care. Review of the hospice calendar for January and February 2023 showed the RN/LVN was scheduled to visit two times per week, and the CHHA was scheduled to visit three times per week. Further review of the hospice calendar showed 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, medical record review, and facility document review, the facility failed to ensure one of 14 final sampled residents (Resident 10) who required hearing aids received proper treatment and assistive device to maintain her hearing abilities. * The facility failed to ensure Resident 10's hearing aids were applied as ordered by the physician. This had the potential for the resident's communication to be impaired by not being to hear conversations clearly. Findings: On 2/7/23 at 1008 hours, during the initial tour of the facility, Resident 10 was observed awake in bed. When Resident 10 was greeted, she did not respond but cupped her hand behind her ear and moved her head closer. When asked if she had hearing aids on or needed her hearing aids on, Resident 10 answered, it would probably make it better. Medical record review for Resident 10 was initiated on 2/7/23. Resident 10 was admitted to the facility on [DATE]. Review of Resident 10's MDS dated [DATE], showed Resident 19 was able to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services related to pressure injuries (areas of damaged skin caused by staying in one position for a long time which reduces blood flow to the area and causes the skin to die and develop a sore to promote wound healing) were provided to one of 14 final sampled residents (Resident 17). * The facility failed to ensure the low air loss mattress setting was consistently monitored to ensure the appropriate settings of the low air loss mattress for Resident 17. This failure posed the risk for complications and delayed wound healing. Findings: Review of the facility's P&P titled Skin Integrity/Prevention of Pressure Injuries revised 11/16/22, showed the policy is to identify and reduce risk factors for the development of pressure injuries. The treatment nurse and Medical practitioner will review the interventions and treatment for effectiveness on an on-going basis. Medical Record 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 observation, interview, and medical record review, the facility failed to provide the necessary respiratory care and services for one of 14 final sampled residents (Resident 538). * The facility failed to ensure Resident 538's nasal cannula tubing (medical device use to deliver supplemental oxygen) was dated. This had the potential for increased risks of infection. Findings: Medical record review for Resident 538 was initiated on 2/7/23. Resident 538 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should). Review of the Order Summary Report showed a physician's order dated 1/31/23, to provide oxygen at two liters per minute via nasal cannula every shift and change oxygen tubing and humidifier every Sunday. On 2/7/23 at 1009 hours, during the initial tour of the facility, an observation of Resident 538 was conducted. Resident 538 was observed in bed receiving…

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, medical record review, and facility P&P review, the facility failed to provide the necessary pharmacy services for one of 14 final sampled residents (Resident 12) and two nonsampled residents (Residents 7 and 18). * Resident 18's hydrocodone-acetaminophen (a narcotic pain medication) Controlled Drug Record documentation did not match Resident 18's MAR. This failure posed the risk of diversion of the controlled medication. * Resident 12's chewable aspirin medication (medication used to lower the chance of heart attack) was administered without the instructions for the resident to chew, and the resident swallowed the aspirin tablet. This posed the risk of decreased absorption of Resident 12's medication. * Resident 7's ferrous sulfate (iron supplement) and calcium (calcium supplement) were administered at the same time. This posed the risk of decreased absorption of Resident 7's ferrous sulfate. Findings: Review of the facility's P&P titled Medication Administration revised date…

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, medical record review, and facility P&P review, the facility failed to ensure four of 14 final sampled residents (Residents 2, 21, 30, and 537) were free from unnecessary psychotropic medications (medication that affects the brain activity). * The facility failed to provide the physician's documentation to extend Resident 30's Xanax medication (psychotropic medication) after 14 days of PRN use and the facility failed to provide a stop date on Resident 30's PRN Xanax ordered on 1/29/23. * The facility failed to provide the non-pharmacological interventions to Resident 21's depression, anxiety, and poor intakes to minimize the use of alprazolam, mirtazapine, and escitalopram medications (psychotropic medications). * The facility failed to accurately document Resident 21's monthly behavior tracking for mirtazapine use. * The facility failed to provide the non-pharmacological interventions to Resident 2's depression to minimize the citalopram use. * The facility failed to ensure Resident 537's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to store the medication and supplies according to the manufacturer's recommendations. * Medication Cart 2 had Resident 16's Novolin R FlexPen insulin injection (medication used to lower blood sugar) with an opened date of 12/29/22, and labeled to expire on 1/27/23. This failure had the potential for the administration of deteriorated medication. * Medication Cart 3 had the expired IV supplies. This had the potential for use of expired supplies. * The facility failed to store the A&D ointment securely and inaccessible by the residents and visitors. This had the potential for unauthorized access to the medication. Findings: Review of the facility's P&P titled Storge and Expiration of Medications, Biologicals, Syringes and Needles revised 4/1/22, showed the facility should ensure that medications and biologicals for expired or discharged residents are store separately, away from use, until destroyed or returned 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 medical record review, the facility failed to provide the rehabilitation services for one of 14 final sampled residents (Resident 30). * The facility failed to ensure Resident 30 was provided RNA services for ambulation when Resident 30 was in isolation for Covid-19. This failure had the potential for Resident 30 to decline in the resident's range of motion and mobility. Findings: On 2/7/23 at 1124 hours, during the initial tour of the facility, an interview was conducted with Resident 30. Resident 30 stated she was supposed to walk, but it was stopped while she was in isolation for Covid-19. Resident 30 stated she was out of the isolation for Covid-19 on Thursday, and the staff started to walk her again. Resident 30 stated she felt she was relearning to walk again. Medical record review for Resident 30 was initiated on 2/7/23. Resident 30 was readmitted to the facility on [DATE]. Review of the MDS dated [DATE], showed Resident 30 was cognitively intact and required extensive assistance 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.