Palos Verdes Health Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to honor one of four sampled residents' (Resident 38) right to self determination by not accommodating Resident 38's request to have a shower.This failure had the potential to negatively impact Resident 38's quality of life.Findings:During an interview on 2/10/2026 at 9:59 a.m., Resident 38 stated she wanted a shower, but staff refused to provide one, and she had not received a shower for some time.During a review of Resident 38's admission Record, the admission Record indicated Resident 38 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including Parkinson's disease without dyskinesia ( a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), unspecified dementia (a progressive state of decline in mental abilities), unsteadiness of feet, and history of falling.During a review of Resident 38's Minimum Data Set(MDS- a resident assessment tool) dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure missing personal items belonging to one of one sampled resident (Resident 47), including colored pencils and pens used for activities and a personal bottle of hot sauce, were located or replaced.This failure had the potential to result in Resident 47 experiencing frustration or depressed mood due to the facility not returning or replacing the missing items. Findings:During a review of Resident 47's admission Record, the admission Record indicated Resident 47 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses of but not limited to major depressive disorder(mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), quadriplegia (paralysis from the neck down, including legs, and arms), bed confinement and chronic pain.During a review of Resident 47's Physician Progress Notes, dated 11/22/2025, 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 ensure one of three sampled residents (Resident 5) was free of chemical restraints (use of medication to control a patient's behavior or restrict the patient's movement and not required to treat the medical symptom).The facility failed to:1.Ensure Resident 5 was provided with non-pharmacological interventions (intervention that does not primarily use medicine) before administering as needed (prn) psychotropic medication (any drugs that affects the brain activities associated with mental processes and behavior) of Ativan (Lorazepam- medicine used to treat anxiety)2.Ensure psychotropic medication used as a prn for Resident 5 did not exceed 14 days.These failures had the potential to put Resident 5 at risk for adverse consequences (unintended, harmful events attributed to the use of medication) due to unnecessary prolonged use of psychotropic medication affecting Resident 5's quality of life.Findings:During a review of Resident 5's admission Record, 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 that the recommended ankle brachial index (ABI- painless test that measures blood pressure in your ankles and arms) with arterial doppler (non-invasive, painless ultrasound test that uses sound waves to evaluate blood flow) for one of 15 sampled residents (Resident 6) was completed as ordered on 1/28/2026 for a right second toe diabetic ulcer (open sore, commonly on the bottom of the foot, affecting resident with diabetes).This failure resulted in Resident 6 experiencing emotional distress due to uncertainty about whether his toe might require amputation( surgical or traumatic removal of a limb or extremity (arm, leg, finger, toe).Findings:During an observation on 2/9/2026 at 10:05 a.m., at Resident 6's bedside. Resident 6's right second toe was observed to be swollen, black in color with a small amount of blood.During a review of Resident 6's admission Record dated 2/11/2026, the admission Recorded indicated Resident 6 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 that one of two sampled residents (Resident 4), who had limited range of motion ([ROM] full movement potential of a joint [where two bones meet]) and limited mobility, received appropriate treatment and services to increase ROM, prevent further decline, and maintain or improve mobility.This failure had the potential to place Resident 4 at increased risk for further ROM decline and the development of contractures (a permanent tightening of muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff).Findings:During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses of but not limited to cerebral infarction (the death of brain tissue resulting from lack of blood supply), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body),…

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 two Certified Nursing Assistants (CNAs) had completed required annual competency evaluations.This failure had the potential to result in residents receiving inadequate care and services due to staff not demonstrating current competency.Findings:During a concurrent interview and record review on 2/12/2026 at 11:06 a.m. with the Director of Nursing (DON), the employee file for CNA 3 was reviewed. The file contained no documentation showing completion of the annual competency. The DON stated CNA 3 did not complete the annual competency and confirmed that annual competencies were required each year. The DON stated that without completing the annual competency, CNA 3 would lack updated knowledge and accountability.During a review of the facility's policy and procedure (P&P) titled Competency of Nursing Staff, dated 3/2025, the P&P indicated All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by state law. In addition, licensed nurses 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 interview and record review, the facility's Quality Assessment and Assurance (QAA a group of people developing and monitoring quality compliance) Committee, failed to ensure effective oversight of facility operations and failed to ensure implementation of the 2025 Plan of Correction (POC) addressing deficient practices identified during the previous 2025 recertification survey.This failure resulted in repeat deficiencies in food storage, food preparation, and sanitation, as well as failure to ensure required annual in-service training for Certified Nursing Assistants (CNAs) was completed.Findings:During a review of the facility's Statement of Deficiencies, dated 5/18/2025, the statement of deficiencies indicated the following repeat deficiencies in food storage, preparation and sanitation and in the required yearly in-service training (education) for the CNA's.During a concurrent interview and record review on 2/12/2026 at 11:42 a.m. with the Administrator (ADM), the facility's Quality Assurance and Performance Improvement (QAPI a data driven proactive approach to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure:a. Education was provided about the benefits and risks of the COVID-19 (an illness caused by the coronavirus and affects the lungs and breathing and can make other parts of the body sick) vaccine for one of five residents (Resident 4) and/or the resident's representative.b. One of five staff (Dietary Aide 1) had documentation containing information demonstrating the staff member had been screened, provided with COVID-19 vaccine education, was offered the vaccine and had their current vaccination status recorded.This failure had the potential to result in residents and staff remaining unprotected against COVID-19, increased risk of serious illness, delayed identification of vaccine status, and missed opportunities to prevent the spread of infection within the facility.Findings:a. During a review of Resident 4's Face Sheet (admission Record), the Face Sheet indicated the facility originally admitted Resident 4 on 9/14/2024 and was re-admitted 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:1. Ensure adequate room size and space to support the comfort and well being of one of 46 sampled residents (Resident 34).This failure had the potential to negatively impact Resident 34's quality of life by limiting his ability to move freely and safely within his living space.2. Ensure 18 of 24 residents' rooms (room [ROOM NUMBER], 102, 103, 104, 106, 107, 108, 109, 110, 116, 118, 215, 217, 219, 221, 223, 229, 231) met the requirements of 80 square feet for each resident.This failure had the potential to result in inadequate provision of safe nursing care and a lack of privacy for residents.Findings:During a review of Resident 34's admission Record dated 2/12/2026, the admission Record indicated Resident 34 was admitted to the facility on [DATE] with the diagnosis including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), muscle weakness and cerebrovascular accident (CVA stroke,…

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 two Certified Nursing Assistants (CNAs) completed the required 12 hours of annual in service training.This failure had the potential to result in a lack of, or delay in, necessary care and interventions for residents due to staff not maintaining required knowledge and skills.Findings:During a concurrent interview and record review on 2/12/2026 at 11:06 a.m. with the Director of Nursing (DON), the employee files for Certified Nursing Assistant (CNA) 3 and CNA 4 were reviewed. The files showed no documentation that CNA 3 completed the required 12 hours of annual nurse aide in-service training. The DON stated that CNA 3 had not completed the required annual in services. The file for CNA 4 showed that the last completion of the required 12 hours of annual in services was on 4/29/2024. The DON stated that the annual 12 hour in service requirement must be completed each year. The DON stated CNAs who do not complete their required in services will lack the necessary knowledge to provide proper care and will have no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) social security checks were not co-mingled (the mixing or combining of funds or assets from different sources into a single account or pool) into the facility's payroll account when Resident 1's social security checks were directly deposited into the facility's payroll account for six months (7/2021-12/2021).This deficient practice resulted in $27,568.37 of Resident 1's social security checks being deposited into the facility's payroll account and used for employee paychecks.FindingsDuring a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with the diagnosis of Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements)During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 4/2/2024, the MDS indicated Resident 1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure funds for one of four sampled residents (Resident 1) were reconciled and returned to Resident 1 within three days of his discharge from the facility (4/28/2024) This deficient practice resulted in multiple social security checks belonging to Resident 1, totaling $27,568.37, being deposited into the facility's payroll account between 7/2021 and 12/2021, without evidence that the funds were deposited to Resident 1's trust account while he was a resident at the facility, or that within 30 days of his discharge from the facility a check was issued to him. This deficient practice had the potential for other resident's funds to be unaccounted for and unreimbursed.Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop a comprehensive care plan for three of four sampled residents (Resident 17, 35 and 14). The facility failed to: 1. Develop care plan for Resident 17's intentional weight loss. 2. Develop care plan for Resident 35 who was receiving Restorative Nursing Aide ([RNA] nursing aide program that helps residents to maintain their function and joint mobility) services. 3. Develop and implement care plan for Resident 14 who had a diagnosis of post-traumatic stress disorder (PTSD-a mental health condition that is caused by an extremely stressful or terrifying event). These deficient practices had the potential to negatively affect the delivery of necessary care and services to Resident's 17,35 and 14. Findings: 1.During a review of Resident 17's admission Record dated 5/17/2025, the admission Record indicated Resident 17 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including morbid obesity (excessive body fat that increases…

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 and interview the facility failed to: 1.Ensure a tray of multiple individually poured orange juices and cranberry juices in the refrigerator were dated. 2.Ensure trays with multiple individually open containers of fruit in the refrigerator were dated. 3.Ensure a container of cooked ham that had an open date of 4/30/25 and use by 5/10/25 was removed from the refrigerator. 4.Ensure a container of cooked chicken with mushrooms in the refrigerator had a use by date. 5.Ensure that multiple containers filled with cold breakfasts cereals had use by dates. 6.Ensure a bag of cooked fish in the freezer had a use by date. 7.Ensure a bag of cooked roast beef in the freezer had a use by date. These failures had the potential to expose residents to food-borne illnesses (any illness resulting from ingestion of food contaminated with bacteria, viruses, or parasites). Findings: During a concurrent observation and interview on 5/16/24. at 6:23 p.m., with the [NAME] in the refrigerator and freezer, observed a tray of multiple individually poured orange juices and cranberry juices…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 42) call light was within reach. This deficient practice had the potential for Resident 42 not to receive necessary assistance when needed, and experienced loss of self-esteem. Findings: During a review of Resident 42's admission Record, the admission Record indicated Resident 42 was admitted to the facility on [DATE], with diagnoses including cerebral infarction (damage to the brain from interruption of its blood supply), and depression ( a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 42's History and Physical (H&P), dated 1/23/2025, the H&P indicated, Resident 42 did not have the capacity to understand and make decisions. During a review of Resident 42's Minimum Data Set ([MDS], resident assessment tool), dated 2/7/2025, the MDS indicated, Resident 42 required partial/moderate assistance (helper does less than half the effort.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one of one sampled resident (Resident 23) had a recommended Level II Preadmission Screening and Resident Review evaluation ([PASARR]-a mental health evaluation done to determine if an individual can benefit from specialized mental health services). This failure placed Resident 23 at risk for inappropriate placement, not receiving necessary care, and services. Findings: During a review of Resident 23's admission Record , the admission Record indicated Resident 23 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including schizophrenia(a mental illness that is characterized by disturbances in thought), depression (a mood disorder characterized by persistent sadness, loss of interest, and changes in thinking, sleeping, eating, and acting), and seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness). During a review of…

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

Based on interview and record review the facility failed to ensure annual performance evaluations were completed for Certified Nursing Assistants (CNA), CNA 1, CNA 2 and CNA 4. This deficient practice had the potential for the facility not to be able to assess areas of weakness identified in performance reviews and skills necessary to provide nursing services to assure resident safety. Findings: During a concurrent interview and record review on 5/18/25 at 2:45 p.m. with the Director of Staff Development (DSD), reviewed CNA1, CNA 2 and CNA 4's employee files. The DSD stated that CNA 1 was hired on 12/18/2023, CNA 2 was hired on 5/28/2024 and CNA 4 was hired on 4/24/2013 . The DSD stated CNA 1, CNA 2, and CNA 4 did not have an annual performance evaluation for 2024. The DSD stated that she did not know performance evaluations were done annually. During an interview on 5/18/25 at 5:09 pm with the Director of Nursing (DON), the DON stated performance evaluations should be conducted annually and that they were used to acknowledge the staff's strengths and to help improve any weaknesses.…

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 reviews, the facility failed to ensure the medication error rate of less than five (5) percent, due to improper medication administration for one of six sampled residents (Resident 31). This failure resulted in seven medication errors out of 26 opportunities and a medication administration error rate of 26.92 percent (%) due to Licensed Vocational Nurse (LVN) 2 failed to administer Resident 31's medication leaving residual medication in the medication cups. Findings: During a review of Resident 31's admission Record, the admission Record indicated Resident 31 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), rheumatoid arthritis (a chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility), and dementia (a progressive state of decline in mental abilities). During a review of Resident 31'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 ensure one of six sampled residents (Resident 31) received the correct dose of hydroxychloroquine (treat rheumatoid arthritis[a chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility] ), vitamin C, memantine (medication used to treat dementia [a progressive state of decline in mental abilities]), metformin ( medication for diabetes mellitus [DM-a disorder characterized by difficulty in blood sugar control and poor wound healing]), multivitamin-mineral, prednisone ( for rheumatoid arthritis) and senna (medication for constipation) as ordered by the physician. This failure had the potential for Resident 31 to have pain, vitamin C deficiencies, high blood sugar, changes in behavior and constipation. Findings: During a review of Resident 31's admission Record, the admission Record indicated Resident 31 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus,…

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 protocol for Antibiotic Stewardship (effort to improve how antibiotics are prescribed and used to ensure they are used effectively, reduce overuse, and prevent antibiotic resistance) for one sampled resident (Resident 23). Resident 23 was prescribed an antibiotic drug without meeting the McGreer criteria, after being screened for right eye swelling and tears. This failure had the potential to result in Resident 23 developing antibiotic resistance (not effectively treating infection) from unnecessary or inappropriate antibiotic use. Findings: During a review of Resident 23's admission Record , the admission Record indicated Resident 23 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including schizophrenia(a mental illness that is characterized by disturbances in thought), depression (a mood disorder characterized by persistent sadness, loss of interest, and changes in thinking, sleeping, eating,…

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 Certified Nursing Assistant (CNA ) had completed required dementia and abuse trainings upon hire and annually for four out of four CNA. 1.CNA 1's hire date on 12/18/2023, CNA 1only had four out of the five required hours of dementia training. 2.CNA 2's hire date on 5/28/2024, CNA 2 only had two out of the five required hours of dementia training. 3.CNA 3's hire date on 4/24/2025, CNA 3 had no dementia or abuse training. 4.CNA 4's hire date on 4/29/2013, CNA 4 only had three out of the five required hours of dementia training and had no abuse training. These failures had the potential to put the safety of the residents at risk. Findings: During a concurrent interview and record review on 5/18/2025 at 2:45 p.m., with the Director of Staff Development (DSD), reviewed CNA 1, CNA 2, CNA 3 and CNA 4's employee files. The DSD stated she was responsible for educating the staff and that all staff were required to receive five hours of dementia training and five hours of abuse training annually. The DSD stated dementia and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure facility staff including Certified Nursing Assistant (CNA 1 had training and competency evaluation on transporting resident using facility van. This failure resulted in, Resident 1's wheelchair tilted back and hit her head on the van lift when Driver 1 made a left turn towards the facility that was slightly uphill slope. Resident 1 sustained a right occipital (the back of the head) scalp laceration (a cut or tear in the skin or underlying tissue) and hematoma (a pool of mostly clotted blood that forms in an organ, tissue or body space), neck sprain (a soft tissue injury that occurs when a ligament [attach bone to bone] in a joint {two or more bones are connected} is stretched too far or torn) and a right shoulder sprain. Resident 1 was discharged from GACH on 10/1/2024 at 6:56 p.m., to Resident 1's home. This failure had the potential for other resident to fall while being transported in the facility van. Findings: During a review of Resident 1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to provide wound treatment to an existing wound for one of three sampled residents (Resident 1), per Resident 1's physician's orders and care plan. This deficient practice resulted in Resident 1's right medial leg wound not be treated or assessed, maggots present in Resident 1's wound and Resident 1's transfer to a General Acute Care Hospital (GACH) for evaluation and treatment. This deficient practice had the potential for worsening of the infection to Resident 1's wound resulting in physical as well as psychological harm related to the presence of maggots in Resident 1's right medial leg wound. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of type 2 diabetes mellitus ([DM] a condition associated with abnormally high levels of sugar in the blood). During a review of Resident 1's Minimum Data Set…

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 staffing information was posted and updated daily. This deficient practice resulted in the inability of residents and visitors to access the facility's staffing information to ensure safe staffing ratios were implemented. Findings: During an observation on 05/14/2024 at 8:12 a.m., observed no posting of nursing hours in any of the two nursing stations. During an interview on 05/14/2024 at 8:15 a.m., the Director of Staff Development (DSD) and the Assistant DSD stated they were not aware of where the nursing hours were posted. DSD stated actual daily staffing hours computed were not posted daily prior to each shift. DSD stated the type of nurses working in each shift was also not posted. During an interview on 05/14/2024 at 10:03 a.m., the Director of Nursing (DON) stated nursing hours should be posted in areas visible to both staff and visitors. The DON stated the facility was not posting actual hours of each nursing staff working prior to each shift. During a review of the facility's policy 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 interview and record review, the facility failed to ensure all Certified Nursing Assistants (CNA), were provided the required dementia (a decline in memory, language, problem-solving and other thinking skills that affect a person's ability to perform everyday activities) care training necessary to ensure the continuing competence of the facility's nursing staff's knowledge and skills. This deficient practice had the potential to result in a delay and interruption of the provision of necessary care and interventions necessary when providing care to dementia residents. Findings: During an interview on 5/16/2024 11:49 a.m., with Certified Nurse Assistant (CNA) 2, CNA 2 stated she has not received all dementia care training and she believes that dementia training would help to take better care of residents with dementia. CNA 2 stated the facility has residents with dementia. CNA 2 stated she takes care of dementia residents, and it was difficult taking care of residents with dementia if she was not trained how. During an interview on 5/16/2024 at 1:13 p.m., with CNA 1, CNA 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide reasonable accommodations form two of three sampled residents (Resident 42 and Resident 16) by failing to: 1.Ensure Resident 42's call light was in functioning condition and able to use. 2. Ensure Resident 16's call light was within reach. This deficient practice resulted in Resident 42 unable to call for assistance when Resident 42 need pain medication and had the potential for Resident 42 and 16 not to receive necessary assistance when needed, and experienced loss of self-esteem. Findings: During a review of Resident 42's admission Record, the admission Record indicated Resident 42 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure (develops when the lungs can't get enough oxygen into the blood), chronic kidney disease, chronic kidney disease (when kidneys have become damaged over time), hypertension (high blood pressure), and hyperlipidemia (elevated level of lipids). During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure three of 14 sampled residents (Resident 21, 4, and t 18) had a Gradual Dose Reduction (GDR, an attempt to decrease or discontinue psychotropic (medication that treats mental illness) on psychotropic medications (any drug that affects behavior, mood, thoughts, or perception) no more than three months after starting unless clinically contraindicated. This deficient practice had the potential to result in Resident 21, Resident 4 and Resident 18 receiving unnecessary use of psychotropic medication. Findings: During a review of Resident 21's admission Record, the admission Record indicated Resident 21 was originally admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses of but not limited to anxiety (feeling of fear, dread, and uneasiness), depression ( persistent feeling of sadness and loss of interest ), schizophrenia (a mental disorder characterized by reoccurring episodes of psychosis that are correlated with 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 store food in a sanitary manner to prevent growth of infectious agents that could cause food borne illness (food poisoning: any illness resulting from the food spoilage or contaminating food) for 39 out of 45 total residents in the facility by failing to: 1. Ensure foods were dated, labeled, and discarded before the use by date (expiration dates). This deficient practice had the potential to affect residents and result in pathogen (germ) exposure and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting (throwing up), diarrhea (loose stool) and fever and can lead to other serious medical complications and hospitalization. Findings: During a concurrent observation and interview on 5/14/2024 at 8:10 a.m., with Dietary Aid (DA) 1 in the kitchen, DA 1 was observed and confirmed there were food items that were not dated and expired in refrigerator and freezer as follows: a. Red pepper, lettuce kept in refrigerator with no…

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's Quality Assessment and Assurance (QAA committees established for the purpose of improving the safety and quality of health services) and Quality Assurance Performance Improvement (QAPI- approach to maintaining and improving safety and quality in nursing homes ) committee failed to implement corrective action to the systemic problems identified: 1. Maintain a system to implement infection control practices including Enhance Barrier Precaution (EBP- use of a gown and gloves for residents with wounds, indwelling devices such as a urinary catheter (a flexible tube that collects urine from the bladder and to a drainage bag), gastrostomy tube (GT-a tube inserted through the wall of the abdomen directly into the stomach for food and medication administration) and tracheostomy (a surgical opening in the neck for breathing) to prevent the spread and transmission of multidrug resistant organism (MDROs- microorganisms, predominantly bacteria that are resistant to one or more classes of antimicrobial agents) in the facility 2. A system to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement their protocol for Antibiotic Stewardship (define) for five of five sampled residents (Resident 11, 19, 25, 247 and 346) prescribed an antibiotic (medication to treat infection) without meeting the McGeer Criteria (a set of clinical definitions used for surveillance in long-term care facilities. These criteria define the resident symptoms and other clinical criteria that are used to meet infection surveillance definitions). This deficient practice had the potential for resident to develop antibiotic resistance (not effective to treat infection) from unnecessary or inappropriate antibiotic use. Findings: 1. During a review of Resident 11's admission Record, indicated Resident 11 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including aphasia (brain disorder where a person has trouble speaking or understanding other people speaking) , dysphagia (difficulty swallowing), gastro-esophageal reflux…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to report an injury of an unknown source to the California Department of Public Health (CDPH) no later than two hours for one of one sampled resident (Resident 1) who had swelling and bruising to the right facial cheek area. This deficient pratice had the potential to result in unidentified abuse in the facility and the failure to protect residents from abuse. Findings: During a review of Residents 43's admission Record , dated 5/16/24 , indicated Resident 43 was admitted to the facility on [DATE] with the diagnoses including, hemiplegia (paralysis or weakness on one side of the body), and hemiparesis (mild loss of strength on one side of the body) following cerebral infarction ( blood vessel in the brain that become blocked causing a lack of oxygen) affecting right dominant side, difficulty in walking, cognitive communication deficit, benign neoplasm of the brain (abnormal growth of non-cancerous cells). During a review of resident 43'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 ensure one of two sampled residents (Resident 42) humidifier and oxygen tubing were labelled with date change. This deficient practice had the potential to place Resident 42 at risk of inhaling contaminated mist through the humidifier and can lead to possible respiratory infections. Findings: During a review of Resident 42's admission Record, the admission Record indicated Resident 42 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure (develops when the lungs can't get enough oxygen into the blood), chronic kidney disease, chronic kidney disease (when kidneys have become damaged over time), hypertension (high blood pressure), and hyperlipidemia (elevated level of lipids). During a review of Resident 42's Minimum Data Set ([MDS], a standardized assessment and care screening tool), dated 3/26/2024, indicated Resident 42's had intact cognitive (ability to think, understand, learn, and remember) status…

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 a larger sized wheelchair for 1 of 24 residents sampled (Resident 4) to promote mobility and maintain independence. This deficient practice had the potential to result in Resident 4 having an increased decline in physical function. Findings: During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was originally admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses including lack of coordination (the ability to use different parts of the body together smoothly and efficiently), muscle wasting and atrophy (decrease in size or wasting away of a body part or tissue), difficulty walking, and obesity (having too much body fat). During a review of Resident 4's Minimum Data Set (MDS-a comprehensive assessment and care screening tool), dated 2/2/2024, the MDS indicated Resident 4 was dependent on nursing staff for toileting, lower body dressing, putting on and taking off footwear,…

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 open date label on morphine sulfate solution (medication for moderate to severe pain) one of one sampled residents (Resident 22). This deficient practice had the potential to placed Resident 22 at risk to received expired medication and result in altered effectiveness of the medication and worsening of the resident's symptoms. Findings: During a review of Resident 22's admission Records, indicated Resident 22 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of colon (cancer in the large intestine), chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), and chronic pain. During a review of Resident 22's Minimum Data Set ([MDS], a standardized assessment and care screening tool), dated [DATE], indicated Resident 22's had intact cognitive (ability to think, understand, learn, and remember) status and decision-making skills. The MDS…

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 on 9/25/2023 the facility failed to physically assist one of one sampled resident (Resident 1) during a transfer from wheelchair to bed resulting in Resident 1 falling and sustaining injuries. This deficient practice of not providing physical assistance to Resident 1 during a transfer resulted in Resident 1 falling and a subsequent transfer to a General Acute Care Hospital (GACH) for treatment. Resident 1 was diagnosed with and treated for a right tibia (larger bone in the lower leg below the knee) and left tibial nailing (surgery to repair a broken bone to keep it stable) secondary to a displaced fracture (bones that are broken and out of alignment) of left proximal tibial (upper part of the left bone that connects to the knee joint) and fibular ([calf bone] and is the smaller bone in the lower leg that connects between the knee and ankles) diaphysis (midsection of a long bone) and displaced fracture of left tibial and fibular diaphysis with patellar (kneecap) placement…

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 adequate orientation, specific competencies and skill sets were assessed for registry staff (independent contractors that take care of patients) and Certified Nurse Assistants (CNA) necessary to care for wandering residents by failing to: 1. Ensure staff were competent and received in-services before providing care to wandering residents (an impaired resident can move about inside the facility without an appreciation of personal safety needs and possibly enter harm's way) in the facility. 2. Ensure the corrective action stated in the facility's Plan of Correction ([POC- is a document submitted by licensed health care facilities to respond to deficiencies identified in a survey of the facility conducted by state field staff were followed and carried out). These deficient practices have the potential for residents to sustain physical and psychosocial harm. Findings: During a review of Resident 1's admission Record (Face Sheet), indicated Resident…

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