Lemon Grove Care And Rehabilitation Center

Based on observation, interview, and record review, the facility failed to ensure a thorough investigation was conducted for an allegation of abuse for one of one resident (Resident 162), when Resident 162 reported a male staff (RNA- restorative nursing assistant 1) inappropriately touched her. This failure had the potential to negatively affect Resident 162's psychosocial wellbeing and the potential to expose all residents in the facility to abuse.Findings: On 12/2/25, the Department of Public Health (CDPH) received a facility reported incident for an allegation of RNA 1 inappropriately touched Resident 162's breast. On 12/15/25 at 9:25 A.M., a concurrent observation and interview was conducted with Resident 162 in her room, curled up in bed. Resident 162 stated RNA 1 touched her breast in her room, but could not recall the date and time it happened. Resident 162 stated there were two unwitnessed incidents with the same staff (RNA 1). Resident 162 stated she informed her roommate (Resident 9) about the second incident. On 12/15/25 at 9:36 A.M., 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to provide a written notice of transfer and its bed hold policy to a resident and his Responsible Party (RP) at the time of his hospital transfer for one of three residents (18) reviewed for closed record. As a result, Resident 18 and his RP were not fully informed of Resident 18's bed hold rights. Findings: Per the facility's admission Record, Resident 18 was readmitted to the facility on [DATE] with diagnoses to include end stage renal disease (End Stage Renal Disease-irreversible kidney failure). On 12/17/25, a review was conducted of Resident 18's medical record. Resident 18's history and physical dated 6/24/25 indicated Resident 18 did not have the capacity to understand and make decisions and the resident's family member (FM) was the RP. Per the facility's Progress Note, dated 11/24/25 at 12 A.M., Resident 18 was transferred to an acute care hospital for a change in condition. There was no documentation on 11/24/25 or 11/25/25 that Resident 18'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, and record review, the facility failed to accurately assess and code two of six residents (130 and 9) for Restorative Nursing Services (RNA-a specially training certified nursing assistant who provides range of motion exercises with residents, in order to maintain mobility and flexibility) on their Minimum Data Set (MDS-a mandated reporting assessment tool) used to inform Centers for Medicare and Medicaid Services (CMS), of residents' current status reviewed for MDS accuracy. This failure resulted in CMS not being informed of Resident 130's and Resident 9's current health status and services being provided.Findings: 1. Resident 130 was admitted to the facility on [DATE], with diagnoses which included cerebral infarction (stroke - a medical emergency where blood flow to part of the brain is suddenly blocked or a blood vessel bursts, depriving brain cells of oxygen and nutrients causing them to die within minutes) affecting the left side (weakness of the left extremities), per 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 ensure a Preadmission Screening and Resident Review (PASSAR 2-a federally mandated process that ensures individuals with serious mental illness (SMI), intellectual disabilities (ID), developmental disabilities (DD), are not inappropriately admitted to Medicaid-certified nursing facilities (NFs) if they can be served in a more integrated, community-based setting) was completed in a timely manner for one of three residents (Resident 129) reviewed for PASSAR.The failure had the potential for Resident 129 to be improperly placed or to miss out on additional services offered for PASSAR II residents.Findings:Resident 129 was admitted to the facility on [DATE], with diagnoses which included schizophrenia (a mental illness that is characterized by disturbances in thought), per the facility's admission Record. An observation and interview was conducted with Resident 129 on 12/16/2025 at 8:15 A.M., in his room. Resident 129 was dressed and neatly…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide individualized therapeutic and or social activities that promote the residents' highest physical, mental, and psychosocial well-being, according to their plan of care for one of three reviewed residents (Resident 23). This deficient practice placed Resident 23 at risk for decreased emotional well-being, social isolation, and reduced quality of life due to the lack of meaningful engagement. Cross Reference F 677.Findings: Resident 23 was readmitted to the facility on [DATE], with diagnoses which included multiple sclerosis (MS, a disease that causes breakdown of the protective covering of nerves, can cause numbness, weakness, trouble walking, vision changes and other symptoms), per the facility's admission Record. On 12/15/25, a review of Resident 23's minimum data set (MDS, a federally mandated resident assessment tool) dated 11/27/25, indicated Resident 23 could make independent reasonable decisions. The MDS also indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to complete post fall assessments for one of one resident (Resident 57) reviewed for accidents according to the facility's policy and procedure. This failure had the potential for not identifying the root cause of Resident 57's falls and maintain Resident 57's safety.Findings: Resident 57 was admitted to the facility on [DATE] with diagnoses including vascular dementia (brain damage affecting thinking, memory, judgment and walking), unspecified severity according to the facility's admission Record. During an observation of Resident 57 on 12/15/25 at 9:30 A.M., Resident 57 was in bed with a floor mat on the right side of the bed. An interview and concurrent record review on 12/17/25 at 3:08 P.M. was conducted with Licensed Nurse (LN) 11. LN 11 stated Resident 57 used to walk independently using a front wheel walker but had declined and preferred to stay in bed most of the day. LN 11 reviewed Resident 57's progress notes from September 2025…

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

Based on observation, interview, and record review, the facility failed to ensure a resident (Resident 5) was positioned properly while tube feeding (TF-nutrition in liquid form through a tube) was ongoing per the resident's plan of care for one of two residents reviewed for TF. As a result, Resident 5 was at risk for aspiration (back up of fluid from the stomach to the lungs) and other TF complications.Findings: Resident 5 was re-admitted to the facility 7/29/25 with diagnoses which included dysphagia (difficulty swallowing) and a gastrostomy (opening in the stomach created surgically), per the facility's admission Record. On 12/16/25 at 9:38 A.M., an observation of Resident 5 in the room was conducted. Resident 5 was lying flat on bed while a TF was infusing. On 12/16/25 at 10:40 A.M., a joint observation of Resident 5 and an interview was conducted with Licensed Nurse (LN) 32. LN 32 stated Resident 5's TF would have been completed at 10 A.M. LN 32 stated Resident 5's head of bed was flat and should have been elevated to prevent Resident 5 from aspiration that could have led 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 assess respiratory status during a nebulizer treatment (liquid medication delivered as a fine mist inhaled into the lungs through a mouthpiece or mask) for two of two residents (Resident 178 and Resident 8) reviewed for respiratory care. This failure had the potential for residents to receive inappropriate care and treatment to address their respiratory problems.Findings: 1.Resident 178 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure with hypoxia (a condition where the lungs fail to adequately exchange oxygen, leading to low oxygen in the blood) according to the facility's admission Record. On 12/17/25 at 8:55 A.M. Resident 178's family member notified Licensed Nurse (LN) 14 that Resident 178 had difficulty breathing. LN 14 informed Resident 178's family member that he will administer a nebulizer treatment to Resident 178 to help with the breathing. LN 14 took a medication in a plastic vial from…

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 address and implement the Consulting Pharmacist's (CP) recommendation during a monthly Medication Regimen Review (MRR) regarding a psychotropic medication (a medication that affects brain function), for one of five residents (Resident 99), for Medication Review. In addition, the CP did not identify monitoring of untoward side effects of anticoagulant (AC, blood thinner medication) for one of two residents (Resident 5) reviewed for AC (Cross Reference F 757). This failure had the potential for Resident 99 not to be monitored appropriately by staff for exhibiting specific behaviors. In addition, Resident 5 was not monitored for untoward side effects of AC for five months.Findings: Resident 99 was admitted to the facility on [DATE], with diagnoses which included paranoid schizophrenia, (a mental illness marked by intense paranoia, delusions [false beliefs, often persecutory], and auditory hallucinations [hearing voices]), according to the facility's…

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

Based on observation, interview, and record review, the facility failed to ensure medications had proper storage and labeling when:1. Two tablets were found loose and unlabeled inside a medication drawer,2. Expired medications were stored inside the medication refrigerator These failures had the potential for medications to be incorrectly administered and decrease medication potency (medication strength) that could compromise the therapeutic effectiveness of stored medications.Findings: 1. A medication storage observation was conducted on 12/17/25 at 7:52 A.M., at station 1. Licensed Nurse 14 (LN 14) opened the second drawer of the medication cart which contained medication cards for residents. A small orange and small white tablet were found loose and unlabeled at the bottom of the drawer. LN 14 stated he was unsure why there were loose tablets in the medication drawer. LN 14 stated the medication cards listed residents' names and drug names. LN 14 stated there should not be any loose and unlabeled medications in the medication cart because staff would not know what the medications…

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 kitchen staff carried out the tasks of the food and nutrition services department in accordance with the standard of practice for the following kitchen competencies: 1. [NAME] (CK) 1 did not demonstrate how to conduct spoon tilt tests (food must hold its shape on a spoon and when tilted, it should fall off with little residue) of pureed food. 2. CK 2 did not know how to calibrate food thermometers. These failures had the potential to expose all residents who consumed food from the kitchen to contract a food-borne illness. Findings: 1.On 12/17/25 at 10:16 A.M., a joint observation of CK 1 performing spoon tilt test of pureed food with the Dietary Services Supervisor (DSS) and the Registered Dietitian (RD) present; and an interview with CK 1 was conducted. CK 1 took the pureed brussels sprouts in a metal bin off the heating rack, took a spoon filled of the pureed brussels sprouts, performed spoon tilt test, returned the spoon filled to the puree, mixed the puree, took another scoop or pureed brussels…

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 obtain written consents and educational proof that residents and their responsible persons (RPs-a person assign to make medical decisions on behalf of the resident) were informed of the risk and benefits for receiving or declining pneumococcal (an immunization protecting against streptococcus pneumoniae bacteria, which causes severe infections) and influenza vaccines (prevents the seasonal flu, a contagious respiratory illness) for two of five residents (Resident 14 and 121), reviewed for vaccinations. As a result, Residents 4 and 121, along with their RPs were not informed of the risks and benefits, if the vaccine was received or declined.1. Resident 121 was admitted to the facility on [DATE], with diagnoses which included schizophrenia (a mental illness that is characterized by disturbances in thought). Resident 121 also had a documented Durable Power of Attorney for medical consent only, according to the facility's admission Record. On 12/18/25 at…

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 obtain written consents and educational proof that residents and their responsible persons (RPs-a person assign to make medical decisions on behalf of the resident) were informed of the risks and benefits for receiving or declining the SARS-COV-2 vaccine (prevents severe COVID-19 illness, a highly contagious respiratory virus), for two of five residents (Resident 14 and 121), reviewed for vaccinations. As a result, Residents 4 and 121, along with their RPs were not informed of the risks and benefits, or if the vaccine was received or declined.Findings:1. Resident 121 was admitted to the facility on [DATE], with diagnoses which included schizophrenia (a mental illness that is characterized by disturbances in thought). Resident 121 also had a documented Durable Power of Attorney for medical consent only, according to the facility's admission Record. On 12/18/25 at 9:39 A.M., Resident 121's clinical record was reviewed for immunizations. According to 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 accurately code the required resident assessment for 1 resident reviewed for accuracy of assessments. This failure had the potential for not identifing Resident 1's needs. Findings: An unanounced visit was made to the facility on [DATE] in response to a report of a fall. Record review was initiatied on 12/10/24. Resident 1 was admitted to the facility on [DATE] with health conditions which ncluded need for assistance with personal care and unspecified hearing loss according to the admission Record. On 12/10/24 at 11:38 A.M., Licensed Nurse (LN) 3 was interviewed. LN 3 stated Resident 1 was deaf, and preferred to have staff write questions to her, and she would answer verbally. On 12/10/24 at 11:40 A.M., Resident 1 was interviewed. The questions were written and answered verbally by Resident 1. Resident 1 laughed when asked if one ear was better than another. Resident 1 stated both ears are crap. On 12/10/24 at 2:10 P.M., an interview and joint review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement their admission policy when one of three residents (Resident 1) was admitted to the facility without sufficient information to determine if appropriate care and services could be provided to the resident. As a result of this deficient practice, the facility sent Resident 1 back to the hospital which had the potential to cause the resident distress. Findings: A review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] and was discharged on 6/19/24. On 11/14/24 at 4:24 P.M., a telephone interview was conducted with Resident 1. Resident 1 stated he met with the facility's admissions marketer (AM) while he was at the hospital. Resident 1 stated he had disclosed his parole status to the AM and that he wore an ankle monitor as a condition of his parole. Resident 1 stated he was admitted to the facility, given a room and bed, and was provided dinner. Resident 1 stated everything was fine until the next…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three residents (Resident 1) was permitted to remain in the facility when the resident was discharged to the hospital without a valid clinical reason. This deficient practice had to potential to cause Resident 1 to experience psychosocial and emotional distress. Findings: A review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] and was discharged on 6/19/24. On 11/14/24 at 4:24 P.M., a telephone interview was conducted with Resident 1. Resident 1 stated he met with the facility's admissions marketer (AM) while he was at the hospital. Resident 1 stated he had disclosed his parole status to the AM and that he wore an ankle monitor as a condition of his parole. Resident 1 stated he was admitted to the facility, given a room and bed, and was provided dinner. Resident 1 stated everything was fine until the next morning when an administrative staff member came into his room and asked about his…

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 update the care plan with resident-specific interventions for one of one resident reviewed for falls (Resident 1). This failure had the potential for Resident 1 to sustain further falls. Findings: According to the admission Record, Resident 1 was admitted to the facility on [DATE] with diagnoses that included muscle weakness, cognitive communication deficit (difficulty with memory and communicating needs) , and early onset Alzheimer ' s disease (a disease which affects memory). A review of Resident 1's MDS (Minimum Data Set, an assessment tool) indicated for showering, Resident 1 was dependent on staff. The MDS indicated, Dependent- Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity. On 9/27/24 at 9:17 A.M., an interview was conducted with Resident 1. Resident 1 stated she had a fall in the shower, while sitting in a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure documentation in the clinical record was accurate for one of two residents (Resident 1) when: 1. Licensed nurses (LN) documented Lithium (a mood stabilizing medication) as having been administered to the Resident 1 when the medication was unavailable. 2. Resident 1 ' s documented behavior monitoring did not reflect accurate observations of the resident ' s behavior. As a result, Resident 1 ' s clinical record did not accurately reflect the care and treatment that was provided. Findings: A review of Resident 1 ' s admission Record indicated, the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include schizophrenia (mental illness characterized by paranoia, hallucinations, and/or delusions) and acquired absence of left upper limb above the elbow. 1. On 9/5/24, a record review was conducted. Resident 1 ' s readmitting orders from [hospital name] dated 8/19/24, indicated the resident was to take Lithium 300…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement resident-centered care plans related to: 1. Resident 47 was not assessed for activities. 2. Resident 42 was not assessed for triggers related to Post-Traumatic Stress Disorder (PTSD- a condition in which a person has difficulty recovering after witnessing or experiencing a terrifying event). 3. The central port (a line used for dialysis access) was not identified or did not provide direction of care for Resident 32. 4. In addition, turning and repositioning was not implemented for Resident 43. As a result, there was not a consistent approach by staff to address residents' care needs. Findings: 1. Resident 47 was admitted to the facility on [DATE] with diagnoses that included fracture of thoracic vertebra (bones of the spine). A concurrent observation and interview was conducted on 8/12/24 at 11:49 A.M. with Resident 47. Resident 47 was observed sitting in her wheelchair in her room, looking out at the garden 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 observation, interview and record review, the facility failed to ensure medications were safely stored when: 1. The medication refrigerator temperature log was incomplete. 2. A food product was found stored in a medication cart. 3. A discontinued medication was not discarded from a medication cart. 4. A medication cart was not locked and unsecured. 5. A medication was left unattended at a resident's bedside. As a result, refrigerator medications could have been ineffective if not stored at the correct temperature, food could cause cross contamination to medications, discontinued medication could have been accidentally been administered, and unauthorized residents, visitors and staff could have access to medications, which could be harmful. Findings: 1. An observation, interview, and record review of the facility's medication room was conducted with the Assistant Director of Nursing (ADON) on 8/15/24 at 8:21 A.M. The refrigerator daily temperature log had missing entries for the day shift (7 A.M. to 3:30 P.M.) on 8/13/24 and 8/14/24. The ADON stated with no documentation of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of three residents (Resident 106) was assisted with a meal in a dignified manner. This failure had the potential for Resident 106 to experience a diminished self-worth. Findings: Resident 106 was re-admitted to the facility on [DATE], with diagnoses which included epilepsy (seizures), per the facility's admission Record. An observation was conducted from the hallway on 8/12/24 at 12:23 P.M. of a staff member feeding Resident 106 in her room. Resident 1 was sitting up in bed and slightly slumped to the right. A staff member was standing on the right side of the bed, feeding the resident a pureed diet (food that has a soft pudding-like consistency). The staff member was standing approximately two feet above the resident's head, looking downward. On 8/12/24 at 12:24 P.M., the staff member was called out from the room. The staff member identified herself as Speech Therapist 1 (ST 1). ST 1 stated she was feeding Resident 106, 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 privacy was provided to one of 29 residents (Resident 32) during personal care. As a result, there was the potential for Resident 32 to feel embarrassed and distressed. Findings: A review of Resident 32's admission Record indicated that the resident was admitted to the facility on [DATE] with diagnoses to include Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). A review of Resident 32's Minimum Data Set Assessment (MDS, a comprehensive assessment tool) dated 7/16/24, indicated the resident scored 03 on the brief interview of mental status (a score of 03 meant the resident was severely cognitively impaired). On 8/12/24 at 9:40 A.M., an observation was conducted from the hallway outside of Resident 32's room. The door opened to Resident 32's room, and certified nursing assistant (CNA) 50 left the room carrying a bag of soiled items. Resident 32 was visible from the hallway while…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide activities of interest for one of one residents (47) reviewed for activities. This failure had the potential to not maintain or improve Resident 47's physical, mental and psychosocial well-being and independence. Findings: Resident 47 was admitted to the facility on [DATE] with diagnoses that included fracture of thoracic vertebra (bones of the spine). A concurrent observation and interview was conducted on 8/12/24 at 11:49 A.M. with Resident 47. Resident 47 was observed sitting in her wheelchair in her room, looking out at the garden and fountain. Resident 47 stated she was bored and did not attend activities because, The games were for 2 year olds. An interview was conducted on 8/14/24 at 9:20 A.M. with the Activity Director (AD). The AD stated, This resident does not want to do activities. An activity/interest assessment was never completed and should have been within five days after admission. A review of Resident 47'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, and record review, the facility did not ensure a resident with a past trauma received trauma informed care in accordance with professional standards of practice in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for one of one residents (42 ) reviewed for trauma informed care. As a result, there was the potential for the resident to not have a sense of emotional and physical safety. Findings: Resident 42 was admitted to the facility on [DATE] with diagnoses that included Post-Traumatic Stress Disorder (PTSD- a condition in which a person has difficulty recovering after witnessing or experiencing a terrifying event) according to the facility's admission Record. A concurrent observation and interview was conducted on 8/12/24 at 3 P.M. with Resident 42. Resident 42 was reclining in his bed, watching TV. Resident 42 only wanted to discuss the weather. A review of Resident 42's care plan was reviewed on 8/13/24 at 8:30 A.M. The care plan,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of four licensed nurses (LN) 10 was competent (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully) to perform medication administration. As result, the medications LN 10 administered to Resident 43 did not consistently adhere to the physician's order, were incompletely given, had hold parameters that were not verified, medications were left unattended, acceptable infection control standards were not implemented, and documentation in the medication administration record (MAR) was inaccurate. These deficiencies had the potential to effect resident safety and the efficacy of treatment. Cross reference F759, F761, F842, and F880. Findings: A review of Resident 43's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses to include hemiplegia and hemiparesis (paralysis…

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 medication error rate was less than five percent. The facility's medication error rate was 8.33 percent. Three (3) medication errors were observed, a total of 36 opportunities, during the medication administration process for two (2) of five randomly observed residents (Residents 10 and 43). As a result, the facility could not ensure medications were correctly administered to all residents. Cross reference F726. Findings: On 8/14/24 at 9:05 A.M., a medication administration was observed with LN 10. LN 10 began to dispense Resident 43's medications into individual, unlabeled medication cups (30 milliliters/ml size), including but not limited to: Lactulose 25 ml (promotes bowel movement) Vitamin D 50 micrograms (mcg) (LN 10 crushed the tablets into a powder). At 9:12 A.M., LN 10 donned personal protective equipment (PPE, gown and gloves) and entered Resident 43's room to administer the medications. LN 10 checked the placement of Resident 43's g-tube (tube surgically inserted through the abdominal…

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 29 sampled residents (Resident 122) received food and drink that was palatable, appetizing, and attractive, when the resident was served nectar thick beverages (liquids that had a thickener added to make the consistency like nectar) and some pureed food items (food blended to a pudding-like texture) without a physician's order or clear indication. As a result, Resident 122 stated she did not want to eat the food which put the resident at risk for unintended weight loss and malnutrition. Findings: A review of Resident 122's admission Record indicated the resident was admitted to the facility on [DATE]. On 8/12/24 at 11:18 A.M., an observation and interview was conducted with Resident 122 while inside the resident's room. Resident 122 stated she did not have teeth and that her teeth had got stolen on the street. Resident 122 was observed with missing teeth. Resident 122 stated she had to eat a pureed diet since being here 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 of medication administration was accurate in one of five residents' (Resident 43) medication administration record (MAR). This failure had the potential to not accurately reflect the treatments provided to residents. Findings: A review of Resident 43's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses to include hemiplegia and hemiparesis (paralysis and weakness) affecting right side following a stroke, hypertension, dementia (memory loss), and gastrostomy (opening into the abdominal wall for insertion of a feeding tube [g-tube]). On 8/14/24 at 9:03 A.M., a medication administration was observed with LN 10. LN 10 began to dispense Resident 43's medications into individual, unlabeled medication cups (30 milliliters/ml size) as followed: 1. Amlodipine 2.5 mg (controls blood pressure [LN 10 crushed the tablet into a powder]) 2. Apixaban 5 mg (anticoagulant [LN 10 crushed 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 ensure one of five residents' (Resident 43) medication administration followed acceptable infection control practices when licensed nurse (LN) 10 attempted to administer a medication that had been disposed of in the trash can. This deficient practice had the potential to expose Resident 43 to infection via the resident's g-tube (a tube surgically placed through the abdominal wall for medication administration and liquid feeding). Cross reference F726. Findings: A review of Resident 43's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses to include hemiplegia and hemiparesis (paralysis and weakness) affecting right side following a stroke, hypertension, dementia (memory loss), and gastrostomy (opening into the abdominal wall for insertion of a feeding tube [g-tube]). A review of Resident 43's physician orders dated 4/11/24, indicated, Enhanced Barrier Precautions: [interventions used to control…

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: 1. Residents were free from physical and verbal abuse when Resident 3, who had a history of hitting others and wandering, wandered around the facility, entered other resident rooms, and start altercations while unsupervised. On five separate occasions (12/26/22, 1/26/23, 2/17/23, 3/13/23, and 9/12/23) Resident 3 entered other residents ' rooms/personal space wherein she yelled and cussed at, pulled hair, slapped, and hit other residents. 2. After Resident 3 had repeatedly verbally and physically abused other residents, the facility failed to implement close supervision of the resident when wandering to prevent further incidents from occurring. 3. This continued failure to provide close supervision when Resident 3 wandered lead to a sixth incident of physical abuse on 1/13/24, when Resident 3 entered Resident 1 ' s room and started an altercation by hitting the resident ' s arms and taking the resident ' s personal items. As a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure its abuse policies were implemented when certified nursing assistant (CNA) 4 did not report Resident 1 ' s allegation of physical abuse. In addition, the facility did not report the allegation of abuse within 24 hours to the California Department of Public Health (CDPH, state survey agency that regulates nursing homes) and law enforcement entity as was mandated by law. As a result of this deficient practice, investigation into the allegation of abuse was delayed and placed residents at risk for further abuse. Cross reference F600. Findings: A review of Resident 1 ' s admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses to include paralysis and weakness affecting the right side of the body following a stroke. A review of Resident 1 ' s Minimum Data Set Assessment (MDS, a comprehensive assessment) dated 12/15/23, indicated the resident scored 15 on the brief interview of mental status (a score of 13-15…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one resident ' s (Resident 3) written care plan for wandering behavior was implemented when incidents of wandering and what diversional activity was attempted were not consistently documented. As a result, the facility could not track Resident 3 ' s incidents of wandering and what diversional activity may or may not have been effective. Cross reference F600 and F609. Findings: A review of Resident 3 ' s admission Record indicated the resident was admitted on [DATE] and readmitted to the facility on [DATE] with diagnoses to include bipolar disorder (a mood disorder characterized by depression and mania) and dementia (characterized by memory loss and lack of judgement serious enough to affect daily activities) with behavioral disturbance and psychotic (abnormal thinking and perception) disturbance. A review of Resident 3 ' s written care plan for Wanderer: Resident self-propelling wheelchair into the hallway and going into other residents ' rooms,…

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 revise/update Resident 3 ' s written care plan to provide close supervision when the resident was wandering around the facility after Resident 3 had incidents of entering other residents ' rooms that resulted in resident-to-resident altercations. As a result of this deficiency, Resident 3 continued to wander into other residents ' rooms and those residents experienced abuse or were at risk for experiencing abuse. Cross reference F600. Findings: A review of Resident 3 ' s admission Record indicated the resident was admitted on [DATE] and readmitted to the facility on [DATE] with diagnoses to include bipolar disorder (a mood disorder characterized by depression and mania) and dementia (characterized by memory loss and lack of judgement serious enough to affect daily activities) with behavioral disturbance and psychotic (abnormal thinking and perception) disturbance. A review of Resident 3 ' s interdisciplinary team (IDT) note dated 12/27/22, indicated 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 and record review, the facility failed to ensure for one of three residents (Resident 1) that: 1. Certified nursing assistants (CNA) completed the required documentation of Resident 1's bowel movements each shift, and 2. Licensed nurses (LNs) followed up on the accuracy and completeness of CNA documentation for Resident 1's bowel movements to determine if bowel protocol (systematic interventions to prevent/address constipation) needed to be initiated. As a result, there was the potential for documentation that was incomplete and not followed up on to affect the residents' health and well-being. Findings: A review of Resident 1's admission Record indicated the resident was admitted to the facility 6/16/23. A review of CNA documentation titled Documentation Survey Report v2, for Resident 1's July 2023 bowel movements indicated, CNAs were required to document each shift (AM shift 7 A.M. to 3 P.M., PM shift 3 P.M. to 11 P.M., and Night shift 11 P.M. to 7 A.M.). The CNA documentation were incomplete with blank entries on: 7/2, 7/8, 7/9, 7/10, 7/14, 7/15, 7/16, 7/19 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 consistently provide catheter (tube inserted into the bladder) care for four of four residents (19, 61, 123 and 126). This failure had the potential to increase the risk of infection for residents. Findings: 1. Resident 19 was admitted to the facility on [DATE], with diagnoses that included paraplegia (partial or complete paralysis of lower half of the body), per the facility's admission Record. According to the Minimum Data Set (MDS, assessment tool), dated 12/14/21, Resident 19 had a Brief Interview of Mental Status (BIMS, an assessment of the resident's ability to remember and reason) score of 13 (13-15 meant cognitively intact) which indicated, the resident was cognitively intact. On 3/14/22 at 3:42 P.M., an observation and interview with Resident 19 was conducted. Resident 19 was seated with a catheter attached to the bed. Resident 19 stated the staff did nothing to clean his catheter. Resident 19 stated the staff did not assist 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 observation, interview, and record review, the facility failed to support one of 29 resident's (81) choice for medical treatment. As a result, Resident 81 was given medication without her consent. Findings: A review of Resident 81's admission record, indicated the facility admitted Resident 81 on 4/26/21 with a diagnosis that included Atrial Fibrillation, a heartbeat that is irregular. A review of Resident 81's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 1/31/22, indicated Resident 81 had the capacity to make her own decisions. During a concurrent observation and interview on 3/16/22 at 1:49 P.M., Resident 81 stated she was able to care for herself and could tell the nurses what she needed. Resident 81 stated she knew what she needed. A review of Resident 81's physicians active orders for March 2022, indicated she received a medication called Digoxin to treat her irregular heartbeat, Atrial Fibrillation. During a concurrent interview and record review with LN 11 on 03/17/22 at 8:23 A.M., LN 11 stated Resident 81 refused her Digoxin. LN…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a safe discharge for one of three sampled residents (146). As a result, Resident 146 was discharged to a homeless shelter where her medical and daily needs could not be met. Findings: Per the facility's admission Record, Resident 146 was admitted on [DATE], with diagnoses which included major neurocognitive disorder (bipolar disorder) and increased need for assistance with personal care. On 3/15/22, a review of Resident 146's records from the acute hospital titled, Discharge Summary Notes, dated, 3/19/21 indicated, .Psychiatry . with history of cancer and major neurocognitive disorder thought to be secondary to chronic alcohol . On 3/15/22, a review of the facility's psychiatrist notes dated 4/23/21, indicated, .Lacks decision making capacity . On 3/15/22 at 10:28 A.M., the Social Services Director (SSD) was interviewed. The SSD stated, Resident 146 was discharged to a homeless shelter on 3/8/22. On 3/16/22 at 10:40 A.M., LN 21 was interviewed.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a comprehensive care plan was developed related to suprapubic catheter (tubing inserted to the bladder through a small hole in the belly to drain urine) care for one of four residents (61) reviewed for catheter care. As a result, Resident 61 was at risk for developing an infection. Findings: Resident 61 was admitted to the facility on [DATE] with diagnoses which included acute kidney failure (when kidneys lost their filtering ability), per the facility's admission Record. According to Resident 61's History and Physical (H & P) dated 11/8/21, the wound physician indicated Resident 61 was self- responsible, alert, and oriented to person and situation. On 3/14/22 at 3:40 P.M., an observation and interview of Resident 61 in his room was conducted. Resident 61 was awake in bed, with catheter bag connected to the bed rail. Resident 61 stated he did not know if the staff were cleaning his catheter. On 3/16/22 at 10:10 A.M., 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.

Based on observation, interview, and record review, the facility did not provide adequate monitoring for one of 29 resident's (81) medical condition. This created the potential for Resident 81 to have higher amounts of drugs in her system and increase the likelihood of side-effects related to her medication orders. Findings: A review of Resident 81's admission record, indicated the facility admitted Resident 81 on 4/26/21, with a chronic kidney disease which impaired her ability to adequately excrete certain medications. A record review of Resident 81's lab values on 12/21/21 showed her chronic kidney disease had progressed to stage four. In stage 4 chronic kidney disease Resident 81 has had severely damaged kidneys with decreased ability to metabolize and excrete certain medications. This increased the accumulation of active drugs in her system and increased her risk for adverse effects, such as mental confusion, from the drugs. A record review of Resident 81's physician's orders for March of 2022 indicated she received Digoxin for her irregular heartbeat. During an interview 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 ensure the Licensed Nurse (LN) followed the physician's order and the facility's policy and procedure prior to administration of medication through a tube feeding (tube surgically inserted into stomach to provide medications and nutrition) for one of one residents (85). This failure had the potential for Resident 85 to not receive the full dose of medications administered. Findings: Resident 85 was admitted to the facility on [DATE], with diagnoses to include hemiplegia (paralysis on one side of the body and gastrostomy (a tube feeding inserted directly into the stomach), per the facility admission Record. On 3/16/22 at 9:22 A.M., an observation of medication administration was conducted with LN 31 in Resident 85's room. LN 31 flushed the gastrostomy tube with 30 cc (30 cubic centimeters) of water before, then administered each medication separately through the tube then flushed the tube with 40 cc of water. On 3/16/22, a record review was…

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

Based on observation, interview and record review, the facility failed to ensure the medication error rate was less than five percent. The facility's medication error rate was 6.25 %. Two medications errors were observed out of 32 opportunities, during the medication administration process for two of 5 randomly observed residents (Resident 62, 69, 84, 85 and 86). As a result, the facility could not ensure medications were correctly administered to all residents. Findings: 1. On 3/16/22 at 9:08 A.M., an observation of medication administration was conducted with Licensed Nurse (LN) 31. LN 31 prepared and administered medication to Resident 62. On 3/16/22 at 2:49 P.M., a concurrent interview and record review was conducted with LN 31. LN 31 stated he administered Cranberry 425 mg to Resident 62. LN 31 stated he did not call the doctor to change or clarify the order. On 3/16/22 a record review was conducted. Resident 62 had a Physician's Order for Cranberry tablet 450 mg (450 milligrams) by mouth one time a day. On 3/17/22 at 8:54 A.M., an interview was conducted with the Director of…

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

Based on observation, interview and record review, the facility failed to identify and discard potentially hazardous food. As a result, all residents were at risk for food borne illness. Findings: On 3/14/22 at 8 A.M., a concurrent observation of the kitchen and interview with the Dietary Supervisor (DS) was conducted. The dairy/ snacks refrigerator had a tray with 12 containers filled with lime-colored jello and nine containers filled with yellow-colored jello. The label on the tray indicated, Prep date 3/10/22, Use by 3/12/22. The DS stated, The jello should have been thrown out. On 3/14/22 at 8 A.M., in the same refrigerator, a tray of sandwiches was observed. All sandwiches were wrapped in cellophane and marked with a black marker indicating what kind of sandwich it was and a label with a date. One sandwich was marked HC and the label indicated, 3/9. DS stated, The HC means ham and cheese and the date on the label is the date it was prepared. The DS further stated, The sandwiches are good for 3-4 days, the ham and cheese sandwich should have been thrown out. On 3/14/22 at 8…

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 meet the requirement for the accommodation of no more than four residents per resident room. This affected two of 65 resident rooms (room [ROOM NUMBER] and 112). rooms [ROOM NUMBERS] were occupied by five resident beds in each room. Findings: On 3/14/22 through 3/17/22, multiple observations were conducted of the five residents who occupied room [ROOM NUMBER] and the five resident beds for room [ROOM NUMBER]. room [ROOM NUMBER] had four residents at the time of this survey. There were no observed problems with the provision of care for the residents on the mornings of 3/14/22 through 3/17/22. Residents were using wheelchairs and Certified Nursing Assistant (CNAs) were able to wheel the residents out of the rooms without difficulty. On 3/14/22 at 3:35 P.M., an interview was conducted with an unsampled resident (105) in room [ROOM NUMBER]. There were no complaints from the resident regarding the number of residents occupying the room.…

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.