Lakeport Post Acute

Based on observation, interview and record review, the facility failed to ensure that the list of information such as the name and the correct Department of the State Survey Agency, & the State Licensure were accurate and written visibly available to all vulnerable residents, staff and visitors. This failure had the potential to result in unreported and uninvestigated complaint or any incident to the State Agency or State Licensing by a resident/s, staff and visitors who may have had concerns and requires advocacy. Findings: During an observation of the facility on 12/14/23 at 2 p.m., inside the glass of the bulletin board in Hall 500 was an approximately a 3x5 inches white paper with posting indicated The Licensing Agency having authority over this facility is: Department of Health Services, Licensing and Certification Division. During a Resident Meeting on 12/13/23 at 2:30 p.m., when residents were asked who attended the Resident Council Meetings, they stated they only knew that there was Ombudsman information posted but were not aware of the name of the State Agency or State…

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

Based on observations, interviews and record reviews, the facility failed to ensure the food was palatable, was served timely and was served at temperatures in accordance with resident preferences for seven out of seven sampled residents (Residents 376, 68, 65, 375, 226, 52 and 50). These failures had the potential to result in residents not eating the food served which could result in weight loss and further compromise their medical status. Findings: During an interview on 12/11/23 at 1:49 p.m., Resident 376 stated he dislike the food at the facility. Resident 376 stated food had no taste and vegetables were soggy. During an interview on 12/11/23 at 1:52 p.m., Resident 68 stated food comes in late, so it was usually cold by the time he gets it. Resident 68 stated food at the facility was not good, bland and had no taste. During an interview on 12/12/23 at 9:10 a.m., Resident 65 stated food at the facility was not great. Resident 65 stated food was very bland and had no taste. Resident 65 stated meal trays comes late so food was already cold when it gets to her. During an interview…

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 and interviews, the facility failed to ensure 1. residents' food items were labeled with name and dated and expired food items were discarded. These failures led to unsafe and unsanitary storage of food. These failures were also a safety risk that could lead to accidental ingestion of expired food items. Findings: During an observation on 12/13/23 at 1:40 p.m., resident's refrigerator was in the staff breakroom. The refrigerator side was broken. During a concurrent observation and interview on 12/13/23 at 1:47 p.m., Unlicensed Staff AA verified she put the jar of minced garlic for the resident in room [ROOM NUMBER] in the refrigerator. Unlicensed Staff AA stated there was no name to identify who this jar of minced garlic belonged to. Unlicensed Staff AA verified the jar of minced garlic was opened but not dated. Unlicensed Staff AA stated she was unable to read the jar of minced garlic expiration date. Unlicensed Staff AA stated resident's food items should be labeled with their name, should…

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 Governing Body (a group of people that has the authority to exercise governance over an organization) failed to ensure to designate or appoint a California Licensed Nursing Home Administrator (NHA) (Administrator is responsible for establishing and implementing policies regarding the management of the facility) who would be legally responsible for establishing and implementing policies regarding the management and operation when: 1) The Administrator in training (AIT) claimed to be the Administrator of the facility, for over 6 weeks including during the recertification survey dated 12/11/23 - 12/14/23. 2) The AIT was licensed by the State of Montana and was currently scheduled to take the reciprocity administrator licensing exam on 12/14/23. 3) The current licensee Administrator for the facility was not present in the building to provide oversite since October 2023 and during the survey on 12/11/-12/14/23. The current administrator was supervising other two facilities which were more than two hours away from this facility, a…

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

Based on observation, interview and record review, the facility failed to ensure the Quality Assurance Committee (QAA) is composed of the required committee members, such as an active licensed Nursing Home Administrator (NHA) of California during the QAPI meeting dated 10/23 & 11/23. This failure had the potential to result in mismanagement of the practices required by the Administrator to keep the vulnerable resident safe and healthy. Findings: During a concurrent observation and interview on 12/14/23 at 2 p.m., inside the glass of the bulletin board in Hall 500 was an approximately a 3x5 inches white paper with posting indicated [the name of the licensee Administrator], which was not the AIT present. When asked the AIT, who was this licensee Administrator whose name was posted on the bulletin board, the AIT stated that he was the licensee Administrator but had not been there for over 6 weeks. When the AIT was asked where the licensee Administrator was, the AIT replied, he had not been there. The AIT was asked for a copy of his current Nursing Home Administrator (NHA) license 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.

Based on observations, interviews and record reviews, the facility failed to 1. ensure staff were offering and performing hand hygiene (HH, a way of cleaning one's hands that substantially reduces potential pathogens (harmful microorganisms) on the hands) to the residents before or after meals for 12 out of 12 sampled residents (Residents 47, 22, 40 11, 48, 50, 24, 63, 52, 72, 2 and 28), when [NAME] 1 did not perform HH and continue to cook eggs after he wiped his gloved hand in front of his shirt, and ensure staff were following the facility's guideline for donning Personal Protective Equipment (PPE, equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) when staff did not wear gloves when she scooped ice in the ice machine located in the kitchen 2. ensure an oxygen tubing was dated when it was changed and ensure there was a humidifier (a medical device used to humidify supplemental oxygen that provides long-lasting moisture for utmost patient comfort during oxygen therapy) when a resident was using an oxygen concentrator (a medical…

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 five sampled residents (Resident 1, Resident 14, Resident 35, and Resident 38, Resident 51) and resident's representative(s) participated in the plan of care when Care Conferences were not held for the last two quarters according to facility Policy and Procedure. This failure had the potential to interfere with the five resident's ability to achieve and maintain their highest level of activity and independent. Findings: (Refer F 745) During an interview with Resident 14 on 12/12/23, at 9:45 a.m., he stated he was concerned about getting out of the facility and back to his apartment. He stated he wanted to be back in (name of town), a town located 43 miles away, where all his friends and family were located. He stated there were rehabilitation facilities in (name of town) he wanted to transfer to, and had told staff of his desire to transfer, but staff had told him that he could not. Resident 14 stated he did not remember being involved in a 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, interviews and record reviews, the facility failed to ensure 1. they were adequately staffed for 21 out of 31 days for CNAs and nine out of 31 days for licensed nurses in 10/2023, 19 out of 30 days for CNAS and 8 out of 30 days for licensed nurses for 11/2023 and 8 out of 12 days for CNAs and 4 out of 12 days for licensed nurses for 12/2023 which resulted in residents' complaints of assistance not being provided by staff in a timely manner and call light not being answered timely for five out of five sampled residents (Residents 380, 376, 68, 332 and 226 ) and residents feeling scared and anxious staff would not get to them on time in case of medical emergency 2. staff were provided in service on Trauma Informed Care (TIC, eliminate or mitigate triggers that may cause re-traumatization of the resident) which could result in staff not knowing how to properly and competently care for residents with trauma and staff inability to identify possible triggers that could result in re-traumatization (the reactivation of trauma symptoms via thoughts, memories, or…

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

Based on interview and record review, the facility did not ensure training materials, resources, and policies and procedures explained all allegations of abuse must be reported in two hours. This failure resulted in staff not knowing the correct timeline to submit an SOC341 (State of California Report of Suspected Dependent Adult / Elder Abuse) (This form documents the information given by the reporting party on the suspected incident of abuse or neglect of an elder or dependent adult.), after they had become aware of an allegation of abuse. Finding: During an interview on 12/13/23, at 12:00 PM, CNA Q stated she would report allegations of abuse to charge nurse and the nurse would report and file an SOC 341. She stated the time to report is 24 hours. During an interview and record review with Director of Staff Development (DSD), on 12/14/23, at 11:15 a.m., she stated Abuse Prevention and Reporting was completed for every new hire and at annual in-services. She stated Abuse Reporting time frame was Two hours if harm and 24 hours if no harm. A review of the resources and documents…

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 coordinate the Medical Doctor's (MD) appointment for Level II Preadmission Screening (PASARR) for one (1) of eight (8) residents, Resident 52. This failure resulted in cancellation of MD's evaluation for mental illness and a delay of care and services needed for Resident 52. Findings: Level II PASARR is a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in a nursing home for long term care. A record review of Resident 52 titled admission record indicated she was initially admitted to the facility on [DATE] with mental conditions of agoraphobia (is afraid to leave environments they know or consider to be safe) with panic disorder, Bipolar II disorder and panic disorder (episodic anxiety). A record review of Resident 52's evaluation titled Level I PASARR dated 9/27/23 was positive indicated a Level II PASARR mental health evaluation from Department of 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 interviews and record reviews, the facility failed to ensure staff were aware of the Basic Care Plan (BCP, a plan that promotes continuity of care and communication among nursing home staff to increase resident safety) completion time frame and BCP's were completed timely for two out of two sampled residents (Residents 40 and 49). These failures had the potential to put residents' safety at risk and for residents not receiving the care that they need. Findings: A review of Resident 40's face sheet (demographics) indicated she was initially admitted to the facility on [DATE]. Her diagnoses included Hyperlipidemia (HLP, high cholesterol is an excess of lipids or fats in your blood), Dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities) and Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). Her Minimum Data Sheet Assessment (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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice when 1. the facility failed to notify the physician of resident's blood sugar of 400 or more for one out of one sampled resident (Resident 49) 2. the facility failed to provide regular scheduled showers for three out of three sampled residents (Residents 65, 49 and 37). These failures could lead to 1. complications associated with Diabetes Mellitus such as hypoglycemia (a condition in which your blood sugar (glucose-body's main energy source) level is lower than the standard range, hyperglycemia (high blood glucose (blood sugar)and stroke (brain attack, occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts). 2. residents looking unkempt, undignified, feeling insecure and uncomfortable. Findings: A review of Resident 65's face sheet (demographics) indicated she was initially admitted to the facility 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to help schedule an appointment for evaluation of a hearing aid device for one resident, Resident 37. This failure resulted in Resident 37 feeling frustrated and angry due to hearing loss and not being able to hear adequately without the use of hearing aid device. Findings: A record review titled admission Record for Resident 37 indicated he was admitted on [DATE] with a condition of Hearing loss. During an observation and interview on 12/12/23 at 11:10 a.m., in Resident 37's room, Resident 37 wore a large headphone while watching television (TV). Resident 37 removed his headphone and was not able to hear what was said to him. This surveyor had to get close to Resident 37's ear and speak loudly for Resident 37 to be able to hear. Resident 37 apologized for not being able to hear well. Resident 37 stated that he requested to get a hearing aid from the Social Worker since July 2023 with no results to this date. Resident 37 stated that he 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 and record review, the facility failed to ensure sufficient and appropriate social services were provided to meet the needs of Resident 1, Resident 14, Resident 51, Resident 38, Resident 35, Resident 52 & Resident 37, when: 1. The facility did not conduct and document an Interdisciplinary Team Meeting and Care Conference for the last two quarters for Resident 1, Resident 14, Resident 51, Resident 38, Resident 35. 2. The facility did not ensure that Resident 52 had the Level II PASARR evaluation by a Medical Doctor's scheduled in 9/23. Failure to attend the scheduled Medical Doctor's appointment for Level II PASARR evaluation resulted in cancellation, and therefore Resident 52 needed to begin with the entire process for PASARR evaluation. Level II PASARR evaluation will determine the proper care and home placement. 3.The facility failed to arrange the Medical Doctor's (MD) appointment for Resident 37's evaluation for Hearing Aide device that was very much needed due to his hard of hearing since…

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

Based on observation, interviews and record reviews, the facility failed to ensure the development of a plant-based menu. This failure had the potential for vegetarian residents to not meet the recommended daily intake (RDI, the average daily dietary intake level that is sufficient to meet the nutrient requirements of nearly all (97-98 per cent) healthy individuals in a particular life stage and gender group) for certain nutrients like protein or vitamins which could further compromise their medical status . Findings: During an interview on 12/13/23 at 2:31 p.m., the RD stated the facility did not have a plant based menu. The RD stated if a resident was vegetarian, they would be served the same food as the resident with a regular diet, however, they would substitute it with vegan option. The RD stated the facility did not have a menu specific to cater to resident who was vegetarian. The RD stated she was not aware having a plant based menu was a standard. When asked if she thought having a plant based menu for the facility was important to meet vegetarian resident's needs, she did…

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

Based on observation, interviews and record reviews, the facility failed to ensure the kitchen walls were in good repair when holes on the walls were noted. This failure could result in rodents and pest accessing the kitchen area through these holes which could put residents at risk for harmful diseases. During a concurrent observation and interview on 12/14/23 at 6:44 a.m., when asked about the multiple holes on the kitchen wall by the dish sanitizing machine, the Registered Dietician (RD) stated she could not identify what those holes were, but it could possibly be screw holes. When asked if those kitchen holes should be covered, she stated she does not know how deep those were, but she would notify maintenance today. The RD stated she conducted environmental rounds in the kitchen monthly. The RD stated she did not recall if she had noted these kitchen holes on her kitchen environmental rounds. During a concurrent observation and interview on 12/14/23 at 12:12 p.m., the Maintenance Director was shown the holes in kitchen wall by the dish sanitizing machine. The Maintenance…

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

Based on interviews and record reviews, the facility failed to ensure that a resident's, Resident 230's, responsible party, act on behalf of Resident 230 in order to support her in decision-making regarding her care, when the facility did not explain the risks and benefits of bed rails to the responsible party, and did not ask for her consent, before installing the bed rails. This failure had the potential to result in injuries to Resident 230 related to entrapment due to her cognitive impairment. Findings: A review of Resident 230's admission Record, dated 7/8/23, indicated that her medical diagnoses included, Vascular Dementia (Vascular dementia is a general term describing problems with reasoning, planning, judgment, memory, and other thought processes caused by brain damage from impaired blood flow to your brain) Severe, With Other Behavioral Disturbances, Unsteadiness on Feet, Need for Assistance with Personal Care, Cognitive Communication Deficit, Unspecified Abnormalities of Gait and Mobility, and Personal History of Healed Traumatic Fracture. The admission record 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.

Based on interviews and record review, the facility failed to ensure that one resident, Resident 71, was provided her medical records within the accepted timeframes after she made an oral request to the Administrator in Training (AIT). This failure had the potential to result in mismanaged care if Resident 71 was not provided her medical records that would help with decision-making with regards to her healthcare and could have a negative impact on her health and well-being. Findings: A review of Resident 71's record indicated that her BIMS (Brief Interview for Mental Status) score was 13 (Score of 13-15 indicated no impairment in cognition). During an interview on 12/14/23, at 10:10 a.m., with Resident 71, she stated she spoke to the AIT and requested if she could have all her medical records which included her physical therapy records, written discharge plan, appointments with her doctor, etc. Resident stated that the Ombudsman advocated for her to get these medical records, but she still has not gotten any. During an interview on 12/15/23, ay 1:25 p.m., with the Ombudsman, she…

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 treat 4 of 6 residents (Resident 1, Resident 2, Resident 4, and Resident 5) with respect, dignity, and kindness when: 1. Resident 1 for waited in pain while seated in her wheelchair in soiled underwear for a half hour or more before she was assisted back to bed and cleaned. 2. Resident 2 sat on the commode or in her soiled underwear for long periods waiting for assistance and waited 2 hours for her pain medication. 3. Resident 4 waited in the toilet once or twice a day or waited 2-4 hours sitting on her soiled or wet adult diapers to get cleaned. 4. Resident 5 laid in her soiled underwear for 45 minutes or more waiting for assistance. This failure resulted in Resident 1 feeling resigned to suffer through her hip pain, Resident 2 crying, feeling the nurse was rude and disrespectful and purposely making her wait, Resident 4 feeling upset, and Resident 5 feeling upset, inadequate, dirty, and disrespected. The failure also has the potential to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the residents were free from accidents for one out of two sampled residents (Resident 1) when there were no new interventions in place when Resident 1 fell on [DATE] and again on 11/10/22 and the nurses did not follow up with the physician regarding a request for X-ray on 1/11/22 to rule out fracture. This failure resulted in Resident 1 complaining of rib pain on 11/11/22 and subsequent hospitalization on 11/14/22 due to a fractured (broken) rib. Findings: During a review of Resident 1 ' s face sheet (demographics), it indicated he was [AGE] years old with diagnoses including repeated Falls, Heart Failure, Muscle weakness and Anemia (a condition in which you lack enough healthy red blood cells to carry adequate oxygen to your body's tissues). His Minimum Data Sheet Assessment (MDS, a standardized assessment tool that measures health status in nursing home residents) dated 11/4/22, Brief Interview for Mental Status Assessment (BIMS,…

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 grievance forms and complaints information were visually accessible and attainable by residents in the Facility without retaliation or fear of discrimination. This failure had the potential to result in violation of resident's rights, maltreatment, neglect, and loss of personal items. During an interview on 6/21/2022 at 2:30 p.m., at the Resident Council meeting in the Dining room, Resident 52 stated, he did not know where to get the grievance form. Resident 70 stated she did not know where the grievance forms was located. Resident 12 stated, he did not know where to get the grievance forms. Residents 52, 26, 70 ,12 & 34 stated they did not know where to find the phone number for the State Agency and how to file complaints. Resident 26 stated he did know where the forms were located. During an observation on 6/21/2022 at 3:30 p.m., Resident 26 wheeled himself to the end of the hallway where the grievance forms would be. Resident 26 did not find any grievance forms. The Ombudsman phone number was posted in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop comprehensive care plans for four sampled residents (Resident 75, Resident 22, Resident 32, and Resident 48), that were individualized and updated to show residents specific care related to their medical needs. These failures could possibly result in residents decline in health, harm, and negatively impact the residents' quality of care and services. Findings: Resident 75 Record review indicated Resident 75 was admitted to the facility on [DATE] with medical diagnoses including Diabetes Mellitus (A chronic disease characterized by high levels of blood sugar) and Muscle Weakness, according to the facility Face Sheet. A nursing note dated 6/09/22 at 6:21 p.m., indicated, This nurse alerted by CNA (Certified Nursing Assistant) staff that this resident [Resident 75] is not acting normal' .her R (Right) ankle is swollen, but not discolored and causing her 9/10 pain (Pain scale from 0 to 10, where 0 means there is no pain, and 10 is 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 Resident 24 During an interview on 6/21/22 at 11:15 p.m., Resident 24 was sitting up at the side of the bed. When asking questions about her care she stated, the care was ok and the food was not that good. Resident 24 stated that her upper dentures were not fitted correctly and she has no lower dentures making it hard for her to eat solid foods. Resident 24 stated she liked her breakfast which was eggs and toast. Resident 24 stated I mash up the egg on the toast and I can eat that. Resident 24 stated she had asked to see a social worker to help her schedule a dentist appointment for her dentures but no one has come. Resident 24stated I cannot eat the food because of my dentures. I cannot chew a lot of the foods and I do not like the pureed foods. Review of Resident 24's Interdisciplinary Team notes for a weight meeting dated 5/19/22 indicated, the resident had a significant weight loss of 7.4% over the last month. During an interview on 6/23/22 at 9:30 a.m., the Registered Dietician was asked about the care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to: 1. Adequately supervise one of four sampled residents, Resident # 33, when he was observed smoking unsupervised in an area of the facility which was not the designated smoking area, and with an oxygen tank that was strapped at the back of his wheelchair. This failure had the potential to result in a burn injury to Resident # 33. 2. Implement interventions and actions to prevent one of six residents (Resident 75) from falling, after she fell and fractured her right ankle at the facility. This had the potential to result in another fall with injury to Resident 75. Findings: 1. During an observation on 6/20/22, at 2:18 p.m., outside the facility's main entrance, Resident # 33 was observed smoking while seated on his wheelchair and under a No Smoking sign. Resident # 33 was smoking without supervision and he was on oxygen via nasal cannula. During an interview with on 6/21/22, at 3:10 p.m., with Unlicensed Staff P, he stated Resident # 33…

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 sufficient staff were available to provide care and services to residents for each shift and ensure that resident needs were met when the facility did not have sufficient staff to assign to the Red Zone (Covid 19 positive residents who were potentially infectious), and resident reported long wait times for call light responses. This failure had the potential to affect infection control, and the quality of care provided and safety to the residents in the facility. Findings: During an interview on 6/20/22 at 1:30 p.m., the Administrator and DON were asked if there were dedicated staff in the Red Zone for the positive COVID19 resident. The response from both Administrator and DON was due to their staffing shortage, they did not have dedicated staff for the Red Zone. There was one staff that worked in the Red Zone Hallway that also provide care to other residents in adjacent rooms. During interviews on 6/20/22 at 11:00 a.m. and 6/21/22 and 9:30…

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 offer a palatable meal to the residents of the facility on regular and pureed consistencies. This had the potential to cause a negative dining experience, loss of appetite and a decrease in caloric intake for the residents of the facility. Findings: During an interview on 6/22/22 at 2:32 p.m., Resident 229, she stated she did not like the food because it was served cold every day. Record Review of Resident 229's BIMS (Brief Interview of Mental Status-A cognition assessment) score dated 6/16/22 was 15, which indicated her cognition was intact. During an interview on 6/21/22 at 11:30 a.m., Resident 178 stated the food did not taste good, and as a result, he had lost a lot of weight at the facility. Record Review of Resident 178's BIMS score dated 5/21/22 was 13, which indicated her cognition was intact During an interview on 6/22/22 at 1:41 p.m., Resident 9 stated she did not like the food because it tasted dry and no flavor. Resident 9 stated she forced herself to eat the food. During a taste tray observation…

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 store and prepare meals in a sanitary manner, when: 1. Expired dairy was found in one of the facility's refrigerators, 2. Flies were observed in the kitchen sitting in the beverage cart, during tray line observation, and; 3. A Dietary Aid (Dietary Aid L) was observed serving beverages, and pulling up his pants in the process without washing his hands before serving more beverages. These failures had the potential to cause foodborne illness and spread of infections to the resident population. Findings: 1. During a concurrent interview and observation on 6/20/22 at 12:45 p.m., one of the facility refrigerators was observed to store two open boxes of thickened dairy milk with expiration dates of 6/19/2022. This was observed by Dietary Aid K, who was present during the observation. Dietary Aid K took the boxes away to discard them. She stated everybody in the kitchen was responsible for checking food in the refrigerators to ensure no expired food products were stored. The facility policy titled, LABELING 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 documentation for 2 of 6 sampled residents (Resident 22 and Resident 79) was complete and accurate, when: 1) Resident 22's documentation on urinary catheter (a tube placed in the body to drain and collect urine from the bladder) care for the month of June, 2022, had several empty boxes, making it unable to determine if he received the care ordered by the physician. 2) Resident 79's closed record did not contain a discharge summary and comprehensive care plan These failures had the potential to result in inability for the interdisciplinary team to determine if required nursing care and services were provided to Resident 22 and Resident 79 as per physician orders, and for the physicians to be aware if their orders had been implemented. Findings: Record review indicated Resident 22 was admitted to the facility on [DATE] with medical diagnoses including Pressure Ulcer (Injury to the skin due to pressure over time) of Sacral (Lower back)…

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 infection control practices when staff did not follow the facility's policy and procedures for infection control when entering Person Under Investigation (PUI) rooms without appropriate PPE (Personal Protective Equipment), and when residents were not cohorted, and staff moved between Red, Yellow and [NAME] zones (Red zone: residents confirmed positive test for Covid-19; Yellow zone: residents suspected of developing Covid-19 and exposed to Covid-19; [NAME] zone: residents who were not exposed and had negative test for Covid-19) potentially increasing the spread of infections. These failures had the potential to spread COVID-19 infections to other residents and staff. Findings: During an observation and concurrent interview on 6/20/22 at 13:00 p.m., CNA I entered resident room [ROOM NUMBER], a Yellow (residents on transmission based precautions due to exposure to Covid19) cohorted room not wearing Personal Protective Equipment…

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 1 of 6 sampled residents (Resident 179), the opportunity to participate in care planning when no care conference meetings (A meeting between healthcare professionals and the resident to decide the resident's needs, discuss the medical team's goals, and discuss the resident's ideas for meeting those needs) were held inviting her to develop her plan of care. This failure had the potential to result in inability for Resident 179 to advocate for her needs, receive information regarding her care, and begin to develop a discharge plan with the interdisciplinary team. Findings: Record review indicated Resident 179 was admitted to the facility on [DATE] with medical diagnoses including Diabetes Mellitus (A chronic disease characterized by high levels of blood sugar) and Gangrene (Localized death and decomposition of body tissue), according to the facility Face Sheet (Facility demographic). Record review of Resident 179's MDS (Minimum Data Set-An…

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

Based on interview and record review, the facility failed to notify the Ombudsman for one discharged resident to the Community, Resident 80. This failure had the potential to result in unsafe discharge, accidents and worsening mental and health care. Findings: A record titled discharge summary dated 4/20/22 revealed Resident 80 had medical diagnoses of Chronic Pulmonary obstructive Disease (COPD), Infection in the leg bone, major depressive and anxiety disorder. Resident 80 lived alone. A Recapitulation of Resident's Stay revealed, Resident admitted with failure to thrive (FTT), COPD, falls at home, early dementia, anxiety/panic attacks, depression, chronic pain, infected left hip. (Name) (Resident 80) was discharged home due to HMO (Health Maintenance Organization) discharge. Medicare Coverage ends on 4/16/2022 Review of a document titled Progress notes dated 4/20/22 at 11:47 a.m. for Resident 80, revealed Licensed Staff C wrote Resident was discharge to home at 11:47 a.m. This nurse went over medication and discharge instructions. Resident assisted by staff. Further 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 and record review, the facility failed to follow the recommendations by the State of California when they did not perform a PASARR (Pre-admission Screening and Resident Review-A federal program implemented to prevent individuals with mental illness (MI), intellectual disability (ID) or related conditions (RC) from being inappropriately placed in a Medicaid certified nursing facilities for long-term care, and ensure these individuals receive specialized services) II (Level 2) screening after 1 of 6 sampled residents (Resident 35) tested positive for a PASARR I (Level 1, initial screen)screening. This finding had the potential to result in Resident 35's inability to obtain specialized services to manage her mental illnesses, which could have resulted in incapacity to attain or maintain her highest practicable physical, mental, and psychosocial well-being Findings: Record review indicated Resident 35 was admitted to the facility on [DATE], with medical diagnoses including Fracture of Left Femur…

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

Based on observation, interviews, and record reviews, the facility failed to provide care in accordance with professional standards of practice to one out of three sampled residents, Resident # 66, when Resident # 66's Controlled Drug Record for Oxycodone/APAP (A combination preparation of the analgesic and antipyretic acetaminophen and the semisynthetic opioid agonist oxycodone with analgesic and antitussive properties) 5/325 MG (milligram) tablet indicated that Licensed Staff A did not sign-out the Controlled Drug Record when she prepared, and after she administered the medication to Resident # 66, and the pharmacy instruction on the medication label indicated that the frequency of the administration of this as needed pain medication was not followed. These failures had the potential to result in physical harm to Resident # 66. Findings: During a concurrent observation, interview, and record review on 6/23/22, at 9:40 a.m., with Licensed Staff B during inspection of Medication Cart # 1, the Controlled Drug Record for Resident # 66's Oxycodone/APAP 5/325 MG tablet indicated that…

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

Based on interview and record review, the facility failed to develop and implement an effective discharge planning process plan for one sampled Resident (Resident 80) when Resident 80 was discharged home without proper discharge planning and without arrangements for potentially needed follow -up services. This failure had the potential to result in undetected worsening medical and mental health conditions, and potential preventable readmissions. Findings: A record titled discharge summary dated 4/20/22 revealed Resident 80 had medical diagnoses of Chronic Pulmonary obstructive Disease (COPD), Infection in the leg bone, major depressive and anxiety disorder. A Recapitulation of Resident's Stay revealed, Resident admitted with failure to thrive (FTT), COPD, falls at home, early dementia, anxiety/panic attacks, depression, chronic pain, infected left hip. (Name) (Resident 80) was discharged home due to HMO (Health Maintenance Organization) discharge. During a record review titled Progress notes dated 4/20/22 at 11:47 a.m. for Resident 80, revealed Licensed Staff C wrote Resident 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 record review, the facility failed to ensure one of six sampled residents (Resident 178) received appropriate respiratory care when: 1. Physician orders were not followed for supplemental oxygen (The use of oxygen as a medical treatment) administration, and; 2. A Licensed Nurse (Licensed Staff M) left Resident 178 alone and unsupervised during the administration of a nebulizer (A device for producing a fine spray of liquid, used for example for inhaling a medicinal drug) treatment. These findings had the potential to result in respiratory failure, harm and death to Resident 178. Findings: 1. Record review indicated Resident 178 was admitted to the facility on [DATE] with medical diagnoses including Chronic Respiratory Failure with Hypoxia (A condition that results in the inability to effectively exchange carbon dioxide and oxygen, and induces chronically low oxygen levels or chronically high carbon dioxide levels), Pneumonia (Lung inflammation caused by a bacterial or viral…

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 Resident 48 Based on interview and record review, the facility failed to ensure resident's medical supervision such as weight loss was assessed and monitored by a Physician to one of four residents, Resident 48. This failure had the potential to results in malnourish, electrolyte imbalance and dehydration. A [AGE] year-old female with history of Parkinson's disease, Dementia without behavioral disturbance, cognitive communication deficit with a BIMS (Brief Interview for Mental Status) score of 4, (Not cognitively intact). During a record review titled Weekly Weights for Resident 48 revealed, on 5/8/2022 weighed 112 lbs., on 5/10 weighted 110.2 lbs., on 6/5 weighed 107 lbs., 6/19 weighed 104.8 lbs. Resident 48 loss 7.2 lbs. approximately within one month. A record review of Resident 48's food intakes revealed 51- 75% most of the time. A record review titled Progress Notes dated 6/22/2022 for Resident 48 written by Registered Dietician (RD) revealed that Resident continues with trending weight loss. In the past 2…

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 observations, interviews, and record reviews, the facility failed to follow its policy and procedure in ordering and receiving non-controlled medications (Pharmaceutical preparations that can only be obtained through a practitioner's prescription dispensed by a pharmacist and are not considered controlled substances under the Controlled Substances Act) for one of nine sampled residents, Resident # 33, when four (4) prescription medications scheduled to be administered on 6/23/22, at 8 a.m., were not available for administration to Resident # 33. Due to this incident, Resident # 33 refused to take the rest of his medications scheduled for 8 a.m., until the facility could provide the missing prescription medications. This failure to administer Resident # 33's medications as scheduled, due to insufficient supply of his prescribed medications to meet his needs, had the potential to result in worsening of his medical conditions. Findings: During a review of Resident # 33's admission Record, dated 6/23/22,…

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 monitor 1 of 6 sampled residents (Resident 32) for episodes of anxiety and depression, for which she was given medications with significant adverse effects. This had the potential to result in administration of unnecessary medications, which could have caused Resident 32 serious harm. Findings: Record review indicated Resident 32 was admitted to the facility on [DATE] with medical diagnoses including Chronic Obstructive Pulmonary Disease (A lung disease characterized by chronic obstruction of lung airflow that interferes with normal breathing) and Major Depressive Disorder (A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), according to the facility Face Sheet. Record review of Resident 32's MDS (Minimum Data Set-An assessment tool) dated 5/16/22 indicated her BIMS (Brief Interview of Mental Status-A cognition assessment) was 4, which indicated her…

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.