Broadway By The Sea

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of three sampled residents, Resident 31, received their meal tray at the same time as their roommates This deficient practice has the potential to compromise residents' dignityFindings: During a review of the admission Record indicated Resident 31 was admitted to the facility on [DATE] with the diagnoses that included Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), osteomyelitis of left ankle and foot (inflammation of bone, due to infection) and non-pressure ulcer (a small open wound found on the skin) of left heel and midfoot.During a review of Resident 31's Minimum Data Set (MDS- a resident assessment tool) dated 12/20/2025, the MDS indicated the resident had the ability to make self understood and the ability to understand others. The MDS further indicated Resident 31 was independent with eating, oral hygiene (the ability to use items to clean teeth), and Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the call light device was within reach for one of five sampled residents (Resident 60).This failure had the potential to delay staff response and prevent Resident 60 from receiving necessary care and services. Findings:During a review of Resident 60's admission record, the admission record indicated Resident 60 was initially admitted to the facility on [DATE] and the last re-admission was on [DATE] with cataracts (a clouding of the lens of the eye), cerebrovascular accident (CVA-stroke, loss of blood flow to a part of the brain) with left side hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), and left side hemiparesis (the weakness of one entire side of the body).During a review of Resident 60's History and Physical (H&P), dated [DATE], the H&P indicated, Resident 60 had the fluctuating capacity to understand and make decisions.During a review of Resident 60's Minimum Data Set (MDS-a resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the physician when Resident 9 refused medications for one of three sampled residents (Resident 9). This failure had the potential to result in delayed care to address the effects of Resident 9's refusal of medication. Findings: During a review of Resident 9's admission Record, the admission Record indicated Resident 9 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including cerebral infarction (stroke - loss of blood flow to a part of the brain), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), anemia (a condition where the body does not have enough healthy red blood cells), and dementia (a progressive state of decline in mental abilities). During a review of Resident 9's Minimum Data Set (MDS - a resident assessment tool), dated 11/22/2025, the MDS indicated Resident 9 had severe cognitive (ability to learn, reason, remember, understand, and make decisions)…

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 its abuse reporting and prevention policy by failing to report an injury of unknown origin to to the California Department of Public Health (CDPH - state licensing and certification agency) and other officials which includes the Long-Term Care Ombudsman, Law Enforcement, and Licensing Agency for Based on interview and record review, for one of one sampled residents (Resident 9). Theis deficient practice resulted in CDPH being unaware of the injury of unknown origin and possible abuse allegation to conduct a timely investigation. This deficient practice had the potential for information to be lost and/or forgotten. Findings: During a review of Resident 9's admission Record, the admission Record indicated Resident 9 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including cerebral infarction (stroke - loss of blood flow to a part of the brain), osteoarthritis (a progressive disorder of the joints,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow it's policy and procedure (P&P) titled, Fall Management System, for one out of two sampled residents (Resident 27) by not investigating an allegation of a fall incident. This deficient practice had the potential for an actual fall for Resident 27 to not be discovered and probable causal factors to not be identified.Findings:During a review of Resident 27's admission Record, the admission Record indicated Resident 27 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses of hemiplegia (cannot move or weak on one side of the body) of the right side and abnormalities of gait and mobility.During a review of Resident 27's Transfer Out Progress Note dated 11/3/2025, the Transfer Out Progress Note indicated Resident 27 was alert and orientated and able to make her needs known and Resident 27 was complaining of pain on the right-hand radiating (pain that travels from one body part to another) up to her right shoulder. 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.

Based on observation, interview and record review, the facility failed to ensure one of two sampled residents (Resident 16) was seen in a timely manner by a Registered Dietician (RD) after an order for a RD consult was placed due to poor oral (PO) intake.This deficient practice had the potential to lead to unintentional weight loss for Resident 16 due to unaddressed poor oral intake. Findings:During a review of Resident 16's admission Record (face sheet), the admission Record indicated Resident 16 was admitted to the facility 12/3/2025 with diagnoses of encephalopathy (a broad term for any widespread brain disease or dysfunction, altering brain function due to infections, toxins, trauma, metabolic issues, or lack of oxygen) and infective endocarditis (a serious infection of the heart's inner lining (endocardium) or valves, usually caused by bacteria entering the bloodstream, though fungi or other germs can also be responsible). The admission Record did not list dementia as one of Resident 16's current diagnoses.During a review of Resident 16's Minimum Data Set (MDS, a resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure effective pain management for one of three sampled residents (Resident 8), as evidenced by failing to assess and document Resident 8's pain level and the effectiveness of the pain medication before and after giving the pain medication.This failure had the potential to result in Resident 8 not being able to get quality sleep, decreased energy and decreased participation in activities and therapy sessions due to unrelieved pain.Findings:During a review of Resident 8's admission record, the admission record indicated Resident 8 was admitted to the facility on [DATE] with osteomyelitis (inflammation of bone or bone marrow, usually due to infection) of right ankle and foot, unstageable pressure ulcer (a full-thickness wound [caused by unrelieved pressure] where the base is hidden by dead tissue, making its true depth and severity impossible to determine until the covering is removed) on sacral area (the triangular bone [sacrum] at 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 document medication administration for one of three sampled residents (Resident 6). This failure had the potential to result in Resident 6 receiving duplicate doses of acetaminophen (medication used to reduce pain or fever) which places residents at risk for liver problems due to taking too much acetaminophen. Findings: During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (damage or disease that affects brain function) and kidney disease. During a review of Resident 6's Minimum Data Set (MDS - a resident assessment tool), dated 11/4/2025, the MDS indicated Resident 6's cognition (ability to learn, reason, remember, understand, and make decisions) was intact. The MDS indicated Resident 6 required supervision when eating and for oral hygiene, required moderate assistance (helper does less than half the effort) for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one out of six sampled residents (Resident 16)'s diagnoses list was updated to reflect her dementia (severe memory, thinking, and reasoning decline that interferes with daily life, caused by diseases damaging brain cells) diagnosis.As a result of this deficient practice, Resident 16 was receiving medications for a dementia diagnosis that was not listed as one of her current problems.Findings:During a review of Resident 16's admission Record, the admission Record indicated Resident 16 was admitted to the facility on [DATE] with diagnoses of encephalopathy (a broad term for any widespread brain disease or dysfunction, altering brain function due to infections, toxins, trauma, metabolic issues, or lack of oxygen) and infective endocarditis (a serious infection of the heart's inner lining (endocardium) or valves, usually caused by disease causing organisms). The admission Record did not list dementia as one of Resident 16's current diagnoses.During…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement infection control measures by failing to ensure Restorative Nurse Aide (RNA -provides specialized care to help patients recover and keep their functional abilities) 1 wore Personal Protective Equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) properly for one of three sampled residents (Resident 71) who was on Enhanced Barrier Precaution (EBP-an infection control measures, primarily in nursing homes, requiring staff to wear gowns and gloves during high-contact care for residents with multidrug-resistant organisms or increased risk factors like wounds/devices, expanding beyond Standard Precautions to prevent MDRO spread where direct contact is likely).This failure had the potential to result in compromised infection control measures and the spread of infection among residents, staff, and visitors.Findings:During a review of Resident 71's admission…

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

Based on observation, interview, and record review the facility failed to follow physician's orders for one out of three sampled residents (Resident 1) who was receiving care from a podiatrist (foot doctor).This deficient practice resulted in Resident 1 not receiving Ciclopirox n 8% (medication to treat nail fungus) for two months (7/14/2025 to 9/16/2025) and had the potential to delay healing of the left and right great toes. Findings: During an observation on 9/15/2025 at 2:55 p.m., Resident 1's right and left great toes appeared thick and discolored (yellowish/ grey color). During a review of Resident 1's admission Record (face sheet), The admission Record indicated Resident 1 was admitted to the facility 7/30/2021 with diagnoses of type 2 diabetes (the body does not regulate blood sugar levels) and history of falling. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 8/7/2025, the MDS indicated Resident 1 had moderate cognitive impairment (a decline in one or more cognitive abilities, such as memory, attention, reasoning, language, 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 obtain Office Visit Summaries from the outpatient physician visits on 7/1/2025 and 9/3/2025 to follow physician treatment recommendations for one of one sampled resident (Resident 1).This deficient practice resulted in Resident 1 not receiving treatment for Onychomycosis (toenail fungus) of the right and left great (big) toes for two months (7/14/2025 to 9/16/2025). Findings: During an observation on 9/15/2025 at 2:55 p.m., Resident 1's right and left great toes appeared thick and discolored (yellowish/ grey color). During a review of Resident 1's admission Record, The admission Record indicated Resident 1 was admitted to the facility 7/30/2021 with diagnoses of type 2 diabetes (the body does not regulate blood sugar levels) and a history of falling. During a review of Resident 1's Minimum Data Set (MDS], a resident assessment tool) dated 8/7/2025, the MDS indicated Resident 1 had moderate cognitive impairment (a decline in one or more cognitive abilities, such as memory, attention, reasoning, language, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was exhibiting signs and symptoms of depression (serious mental condition that negatively affects how one feels, thinks, and acts), and had an order for psychiatric evaluation (medical doctor specializing in the diagnosis, treatment, and prevention of mental, emotional, and behavioral disorders) on 2/27/2025, 3/11/2025, and 6/3/2025, was seen by the psychiatrist as ordered and signs and symptoms of depression were monitored as indicated in Resident 1's Care Plan. These failures resulted in Resident 1 experiencing worsening symptoms of depression which included loss of interest in activities and excessive sleepiness. These failures had the potential for Resident 1 to have intense feelings of sadness, hopelessness which could lead to suicidal thoughts, attempts, and even death. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure one of three sampled resident's (Resident 1) call light (a device used by residents to call for assistance from facility staff) was within reach. This deficient practice resulted in Resident 1 looking for but not being able to locate find her call light. This deficient practice had the potential for Resident 1 to get out of bed without assistance causing a fall and injury. 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 diagnoses including neurocognitive disorder with Lewy bodies (progressive brain disease that causes a decline in thinking abilities), adult failure to thrive (decline in their overall health and well-being) and a history of falls. During a review of Resident 1's History and Physical (H&P), dated 2/11/2024, the H&P indicated, Resident 1 did not have the capacity to understand and make decisions. 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 one of three Licensed Vocational Nurses (LVN 2) license was active. This deficient practice resulted in LVN 2 working 61 shifts with an inactive license. Findings: During a review of a letter from the California Department of Consumer Affairs Board of Vocational Nursing and Psychiatric Technicians (BVNPT) dated 5/6/2025, the letter indicated as of 2/1/2025 LVN 2's license was inactive due to failure to renew, and as of 5/6/2025, LVN 2's license was currently inactive. During a review of LVN 2's Employee Time Details (Timecard) dated 2/2025, the Timecard indicated LVN 2 worked a total of 18 shifts from 2/1/2025 to 2/28/2025. During a review of LVN 2's Timecard dated 3/2025, the Timecard indicated LVN 2 worked a total of 20 shifts from 3/1/2025 to 3/31/2025. During a review of LVN 2's Timecard dated 4/2025, the Timesheet indicated LVN 2 worked a total of 20 shifts from 4/1/2025 to 4/30/2025. During a review of LVN 2's Timecard dated 5/2025, the Timecard indicated LVN 2 worked a total of three shifts from 5/1/2025 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 intervene and document wound care prevention and management according to professional standards of practice and per the facility ' s policy and procedure titled, Skin and Wound Monitoring and Management, for 2 of 3 sampled residents (Residents 1 and 2) by failing to: 1. Document wound care treatments ordered by the physician in the treatment record for Resident 1. 2. Document Resident 2 ' s wound measurements upon admission. 3. Order and treat Resident 2 ' s moisture associated skin damage (MASD – skin damage caused from prolonged exposure to moisture) upon admission. These deficient practices had the potential to cause harm to Resident 1 and Resident 2 by worsening their wounds/skin conditions, due to lack of accountability, not ascertaining a baseline to monitor worsening of a wound, and the possibility of not providing treatments as ordered which could cause wounds to worsen. These deficient practices also had the potential to cause…

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 two of three sampled residents (Resident 2) who was a high risk for falls was supervised and assisted. The facility failed to ensure the 1:1 sitter (a health care professional who provides constant care and supervision for a patient) assigned to Resident 2 was frequently monitoring and providing visual checks while Resident 2 was in the restroom. This deficient practice resulted in Resident 2 sustaining three unwitnessed falls in the month of 1/2025. Findings: During a review of Resident 2 ' s Face Sheet, the Face Sheet indicated Resident 2 was admitted on [DATE] with diagnoses of cerebral infarction (when the blood flow to the brain is disrupted due to issues with the arteries that supply it), dementia (dementia (a progressive state of decline in mental abilities) and atrial fibrillation (A. Fib, an irregular heartbeat). During a review of Resident 2 ' s MDS dated [DATE], the MDS indicated Resident 2 ' s cognition was moderately impaired 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 implement its Infection Prevention and Control Program by failing to: 1. Ensure all facility staff including registry staff (personnel provided by a placement service on a temporary or on a day-to-day basis) were tested according to local health department guidance. 2. Ensure all facility staff were provided in-services (a type of training that takes place in a nursing workplace to update nurses on the latest information and skills, which can improve patient care) regarding COVID-19 (a potentially severe respiratory illness caused by coronavirus and characterized by fever, coughing, and shortness of breath) protocols. These failures placed residents, staff, and the community at higher risk for cross contamination, and increased spread of COVID-19 infection in the facility and the community. Findings: During an interview on 1/21/2025 at 1:10 p.m. with Certified Nurse Assistant 1 (CNA 1), CNA 1 stated he was from a staffing registry, and he did not perform a COVID-19 test prior to the start of his shift. During an interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 3) grievances related to call lights were resolved to prevent recurrence. This deficient practice resulted in Resident 3 filling similar grievances on 12/2024 and 1/2025. Findings: During a review of Resident 3 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 3 was admitted to the facility on [DATE] with diagnoses including removal of right ankle internal fixation (the use of mental implants to realign and stabilize broken bones). During a review of Resident 3 ' s Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 11/2024, the MDS indicated Resident 3 ' s cognition was intact and required partial/moderate assistance from facility staff with Activities of Daily Living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 3 ' s Grievance Resolution Form dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), nephrostomy tube (a thin, flexible tube that drains urine from the kidney into a bag outside the body) and suprapubic catheter (a flexible tube that drains urine from the bladder through a small incision in the lower abdomen) was monitored and treated. These deficient practices had the potential to result in infection, dislodgement (the action of something moving or being removed from a fixed position), an/or other complications related to Resident 1 ' s nephrostomy tube and suprapubic catheter. 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] and readmitted on [DATE] with the diagnoses including hydronephrosis (a condition where one or both kidneys become stretched and swollen as the result of a build-up of urine inside them) and obstructive uropathy (urine cannot drain through the urinary tract).…

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 Restorative Nursing Aide (RNA, nursing aide program that help residents maintain any progress made after therapy intervention to maintain their function) programs for two of 9 sampled residents (Resident 27 and 31) were modified by qualified and competent staff. 1. For Resident 27, Restorative Nursing Assistant 1 (RNA 1) and Restorative Nursing Assistant 2 (RNA 2) modified Resident 27's RNA program. 2. For Resident 31, RNA 3 modified Resident 31's RNA program independently. This deficient practice placed the residents in the facility at risk for harm and injury and had the potential to result in inaccurate and inappropriate provision of necessary care and services, inaccurate assessments and interventions, and compromised skin integrity resulting in skin breakdown (tissue damage caused by friction, shear, moisture, or pressure). Findings: 1. During a review of Resident 27's admission Record, the admission Record indicated 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: a) a) One of two sampled resident (Resident 60)'s informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for a Seroquel (a psychotropic drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) to treat mental illness was updated. b) One of two sampled resident's (Resident 23) had a medical diagnosis indicated for use of haloperidol (psychotropic). This failure had the potential to for residents to receive unnecessary psychotropic medications which can lead to a risk of increased falls, confusion, or death. Findings: a) During a review of Resident 60's admission Record, the admission Record indicated Resident 60 was originally admitted to the facility on [DATE] with diagnoses including bipolar disorder (sometimes called manic-depressive disorder; mood swings that range 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 observation, interview and record review, the facility failed to administer medications appropriately for three (Residents 24, 69, and 140) of five residents observed during the medication pass. During medication pass, there was one medication error for Resident 24, one medication error for Resident 69, and five medication errors for Resident 140 for a total of 7 medication errors out of 31 opportunities. These medication administration errors resulted to a medication error rate of 22.58%. Findings: a. During a review of Resident 24's admission Record, the record indicated Resident 140 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of atherosclerotic heart disease (condition where plaque builds up in the arteries of the heart) and myocardial infarction (MI- heart attack). During a review of Resident 24's History and Physical (H&P), dated 10/25/2024, the H&P indicated resident had the capacity to understand and make decisions. During a review Resident 24's Order…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 140) was free from significant medication error by failing to ensure Licensed Vocational Nurse (LVN)2 administered five medications individually and not crushed together. This deficient practice potentially resulted in unsafe combinations of medications and had the potential of altering the composition of medications rendering it less effective. Findings: During a review of Resident 140's admission Record, the record indicated Resident 140 was admitted to the facility on [DATE]. During a review of Resident 140's Initial admission record dated 11/5/2024 9:40 p.m., the record indicated Resident 140 was alert and oriented to time, place, person, and situation. During an interview on 11/6/2024 at 8:02 a.m., with Resident 140, Resident 140 stated he was in the hospital for two months because he had a stroke (loss of blood flow to a part of the brain) and had a gastrostomy (G-tube - a surgical…

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: a. Failed to ensure facility staff 1did not leave medication on one of three residents (Resident 8)'s bedside table. b. Failed to ensure Resident 12's budesonide (class of medication used to treat inflammation - swelling) had an open date. Findings: a. During a review of Resident 8's admission Record, the admission Record indicated Resident 8 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), obesity (disorder that involves having too much body fat), unspecified joint contracture (a limitation in the passive range of motion of a joint) and need for assistance with personal care. During a review of Resident 8's Minimum Data Set ([MDS]), a resident assessment tool), dated 10/17/2024, the MDS indicated Resident 8's cognitive skills (ability to think and reason) for daily decision-making were severely impaired. The MDS indicated Resident 8 required supervision with eating 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: 1.Ensure proper labeling of open dates for seven seasoning containers. 2.Ensure staff wore a hair net properly while handling dishes in the dishwashing area. These deficient practices had the potential to cause food-borne illnesses. Findings: a.During a concurrent observation and interview on 11/5/2024 at 8:55 a.m. with [NAME] 1, in the Kitchen, observed, there were seven seasoning items without open dates on the 1st shelf above the food preparation equipment area. [NAME] 1 stated that the seven seasoning containers did not have the open dates. [NAME] 1 stated that staff need an in-service regarding open dates, and that the items should be marked with the open dates to ensure every food item is used before the expiration dates. b.During a concurrent observation and interview on 11/5/2024 at 8:55 a.m. with [NAME] 1, in the Kitchen, the right side of Dietary Aid (DA) 1' hair was exposed around the right ear. DA1's hair reached DA 1's right shoulder and the left side of DA1's hair exposed was exposed as well.…

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 Joint Mobility Assessments (JMA, a brief assessment of a resident's ROM in both arms and both legs) for three of eight sampled residents (Residents 15, 29, and 34) were completed by a Physical Therapist (PT, licensed professional aimed in the restoration, maintenance, and promotion of optimal physical function) and/or Occupational Therapist (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities). 1. For Resident 15, Occupational Therapy Assistant 1 (OTA 1) performed Resident 15's Quarterly JMA on 7/15/2024. 2. For Resident 29, OTA 1 performed Resident 29's Quarterly JMA on 8/8/2024. 3. For Resident 34, OTA 1 performed Resident 29's Quarterly JMA on 8/30/2024. This deficient practice had the potential to result in inaccurate assessments, inappropriate recommendations for care, harm, and inaccurate provision of care and services. Findings: 1. During a review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY CROSS REFERENCE TO F688 Based on observation, interview, and record review, the facility failed to ensure Restorative Nursing Aide (nursing aide program that help residents maintain any progress made after therapy intervention to maintain their function) services provided were accurately documented for two of nine sampled residents (Resident 27 and 31). a. For Resident 27, Restorative Nursing Assistant 1 (RNA 1) and Restorative Nursing Assistant 2 (RNA 2) failed to accurately document passive range of motion (PROM, movement at a given joint with full assistance from another person) exercises provided during RNA sessions in October 2024 and November 2024. b. For Resident 31, RNA 3 failed to accurately document right upper extremity splint application. This deficient practice had the potential to negatively impact the provision of necessary care and services due to the inaccurate reflection of services provided. Findings: During a review of Resident 27's admission Record, the admission Record indicated 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: a. Provide annual documentation verifying the review of their Infection Prevention and Control Program (IPCP) policies and procedures. b. Ensure the Director of Staff Development who was also the interim (temporary) Infection Preventionist Nurse (DSD/IPN), Licensed Vocational Nurse (LVN)1 and Certified Nurse Assistant (CNA)1 wore an isolation gown (protective apparel used to protect the wearer from the transfer of microorganisms and body fluids) while providing direct contact care to two out of three residents (Resident 1 and 40) who were on Enhanced Barrier Precautions (EBP, infection control intervention using gown and gloves during high contact resident care activities designed to reduce the transmission of multi-drug resistant organisms). These deficient practices had the potential to result in the spread of infections in the facility and cause undue harm to the residents' health and well-being. Findings: During a concurrent interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to conduct the quarterly Interdisciplinary Team (IDT-team of health care professionals that work together toward and prioritize the resident 's needs) care conference involving one of three sampled resident's (Resident 25) Family Member 1 (FM 1). This deficient practice violated Resident 25 and FM 1's rights to be informed and the right to participate in resident's plan of care. Findings: During a review of Resident 25's admission Record, the admission Record indicated Resident 25 was originally admitted to the facility on [DATE] with diagnoses including type 2 diabetes (disorder characterized by difficulty in blood sugar control and poor wound healing), dementia (a progressive state of decline in mental abilities), and Alzheimer's disease (a disease characterized by a progressive decline in mental abilities). During a review of Resident 25's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 10/16/2024, the MDS 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's interdisciplinary team (IDT-a coordinated group of experts from several different fields who work together) failed to ensure that a resident was assessed to determine if the resident is capable to self-administer medications for one of one sampled resident (Resident 69). This deficient practice had a potential for resident to self-administer respiratory medications incorrectly resulting in subtherapeutic (below the level necessary to treat effectively) medication effects which can lead to unresolved wheezing (caused by narrowing or blacked airways in the lungs) or difficulty breathing. Findings: During a review of Resident 69's admission Record, the record indicated Resident 69 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of asthma (a chronic lung disease that causes the airways to narrow and swell, making it difficult to breathe) and allergic rhinitis (condition that causes sneezing, congestion, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure one of one sampled resident (Resident 25) was assessed for use and received informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered), and physician order for Resident 25's bolster (long pillows at the foot of the bed). The deficient practice resulted in a violation of resident rights to be free from restraints (any manual method, physical or mechanical device, equipment, or material that is adjacent to the resident's body, cannot be removed easily by the resident, and restricts the resident's freedom of movement). Findings: During a review of Resident 25's admission Record, the admission Record indicated Resident 25 was originally admitted to the facility on [DATE] with diagnoses including type 2 diabetes (disorder characterized by difficulty in blood sugar control and poor wound healing), dementia (a progressive state of decline in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report one of one resident's (Resident 25) unknown injury to the California Department of Public Health (CDPH), when Resident 25 was observed with left lower leg bent inward towards the resident possibly indicating fracture (broken bone) on 2/9/2023. This deficient practice resulted in CDPH's inability to investigate the report of unknown injury timely and had the potential for other cases of unknown injuries to go unreported. Findings: During a review of Resident 25's admission Record, the admission Record indicated Resident 25 was originally admitted to the facility on [DATE] with diagnoses including type 2 diabetes (disorder characterized by difficulty in blood sugar control and poor wound healing), Dementia (a progressive state of decline in mental abilities), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), and contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion)…

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 investigate one of one resident's (Resident 25) unknown injury after Resident 25 was observed with the left lower leg bent inward towards the resident possibly indicating a fracture (broken bone) on 2/9/2023 and report the results of the investigation to the California Department of Public Health (CDPH) within five working days of the incident. This deficient practice resulted in CDPH's inability to investigate the report of unknown injury timely and had the potential for other cases of unknown injuries to go unreported. Findings: During a review of Resident 25's admission Record, the admission Record indicated Resident 25 was originally admitted to the facility on [DATE] with diagnoses including type 2 diabetes (disorder characterized by difficulty in blood sugar control and poor wound healing), Dementia (a progressive state of decline in mental abilities), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one of three sampled resident's (Resident 55) Preadmission Screening and Resident Review (PASARR - a federal assessment requirement to help ensure that individuals who have a mental disorder -MD- are placed in facilities that can provide the appropriate care) screening was completed upon readmission on [DATE]. This deficient practice had the potential to result in inappropriate placement and unidentified specialized services for Resident 55. Findings: During a review of Resident 55's admission Record, the admission Record indicated Resident 55 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 55'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 observation, interviews and record review, the facility failed to initiate a care plan for the Restorative Nursing Assistant ([RNA] assist the patient in performing tasks that restore or maintain physical function as directed by the established care plan) for splinting (a technique that uses a device to immobilize (prevent movement) a joint or limb to help with pain control, injury stabilization, and/or tissue healing) for one out of two residents (Resident 31). This deficient practice had the potential to negatively affect the delivery of necessary care and services including skin breakdown, pain, or harm to the resident. 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 that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (a condition that causes weakness or an inability to move on one side of the body) following cerebral infarction…

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 monitor and monitor and document the condition of a suprapubic (a urinary catheter that is inserted into the bladder [a hollow organ that stores urine] from a small cut in the lower area of the stomach) catheter (a flexible tube inserted into an opening in the body) stoma (a surgical hole) site for signs and symptoms of infection, skin breakdown, unusual odor, and secretions. as ordered by the physician for one of two residents (Resident 61). This deficient practice has the potential to delay the detection of early signs or symptoms of infection. Findings: During a review of Resident 61's admission Record, the admission Record indicated the facility admitted Resident 61 on 5/9/2024 and readmitted him on 7/19/2024 with diagnoses including urinary tract infection (an infection in any part of the urinary system), and obstructive reflux uropathy (UTI-condition that affect the urinary tract and can cause urine to flow abnormally). During a review of Resident 61's Minimum Data Set (MDS-a resident assessment tool),…

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

CROSSREFERENCE TO F842 Based on observation, interview, and record review, the facility failed to provide treatment and services to one of eight sampled residents (Residents 27) to prevent and/or limit a decline in joint (where two bones meet) range of motion (ROM, full movement potential of a joint) by failing to provide Resident 27 with Restorative Nursing Aide (RNA, nursing aide program that helps residents maintain their function and mobility) passive ROM (PROM, movement at a given joint with full assistance from another person) exercises, three times a week as ordered. This deficient practice had the potential to cause Resident 1 to have a decline in ROM of both arms, contracture (loss of motion of a joint) development, and a decline in physical functioning such as the ability to eat, dress, and bathe. Findings: a. During a review of Resident 27's admission Record, the admission Record indicated the facility admitted Resident 27 on 12/4/2017 with diagnoses including rheumatoid arthritis (chronic autoimmune inflammatory disease that affects the joints) of both hands 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 the Registered Dieticians recommendations to increase the tube feeding (medical procedure that provides nutrition, fluids, to people who are unable to eat or drink safely by mouth) was carried out in a timely manner. This deficient practice had the potential to result in the resident's weight loss which can result in negative health outcomes. Findings: During a review of Resident 25's admission Record, the admission Record indicated Resident 25 was originally admitted to the facility on [DATE] with diagnoses including type 2 diabetes (disorder characterized by difficulty in blood sugar control and poor wound healing), dementia (a progressive state of decline in mental abilities), and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) status. During a review of Resident 25's Minimum Data Set (MDS), a standardized assessment and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of one resident (Resident 34), who was diagnosed with post-traumatic stress disorder (PTSD - mental health condition that can develop after someone experiences or witnesses a traumatic even), received trauma informed care (a model that aims to provide effective mental health services by considering a person's past experiences with trauma). This deficient practice had the potential to result in resident re-traumatization and can be detrimental for the resident's psychosocial status. Findings: During a review of Resident 34's admission Record, the record indicated Resident 34 was admitted to the facility on [DATE] with a diagnosis including depression (mental health condition characterized by persistent sadness or loss of interest in activities), and PTSD. During a review of Resident 34's Minimum data Set (MDS), federally mandated assessment tool, dated 10/16/2024, the MDS indicated Resident 34's cognition was moderately impaired, and Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Responsible Party (RP 1) for one of five sampled residents (Resident 8) was informed when the dosage and frequency of Resident 8's medication ([Ativan] used to treat anxiety [extreme worry]) was changed. one of five sampled residents (Resident 8) Responsible Party (RP) was notified when Resident 8's medication dosage and frequency was changed. This deficient practice resulted in Resident 8's RP not being aware of or understanding the change in Resident 8's medication regimen and had the potential for unnecessary medication administration and side effects/adverse reactions to the unnecessary medication. Findings: During a review of Resident 8's admission Record (Face sheet), the Face Sheet indicated Resident 8 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, vascular dementia with severe agitation, palliative care (specialized medical care that focuses on providing relief from pain and other symptoms of 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 interview and record, the facility failed to ensure an injury of unknown origin was reported to the California Department of Public Health (CDPH) for one of seven sampled residents (Resident 1) when Resident 1 sustained a reddish-purple discoloration to the left arm and right rib flank. This deficient practice resulted in the inability of CDPH to investigate Resident 1's injury of unknown injury in a timely manner and had the potential for facts related to the injury to be forgotten by staff. Findings: During a review of Resident 1's admission Record (Face sheet), the Face sheet indicated Resident 1 was admitted to the facility with diagnosis including chronic obstructive pulmonary disease (a lung disease causing restricted airflow and breathing problems), chronic kidney disease (a ,long term condition where the kidneys do not work well as they should) and anemia (a condition that develops when the blood produces a lower than normal amount of healthy red blood cells). During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool)…

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

Based on interview and record, the facility failed to conduct a investigation for one of five sampled residents (Resident 1) when Resident 1 reported he was attacked by nursing staff and when reddish-purple discoloration was found on Resident 1's the left arm and the right rib flank area. This deficient practice resulted in the inability of the facility to determine what might have been the cause of Resident 1's injury and had the potential to recur. Findings: During a review of Resident 1's admission Record (Face sheet), the Face sheet indicated Resident 1 was admitted to the facility with diagnosis including chronic obstructive pulmonary disease (a lung disease causing restricted airflow and breathing problems), chronic kidney disease (a ,long term condition where the kidneys do not work well as they should) and anemia (a condition that develops when the blood produces a lower than normal amount of healthy red blood cells). During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 6/12/2024, the MDS indicated Resident 1 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure all items on the inventory list for one of three sampled residents (Resident 1) was accounted for when the facility failed to review and sign Resident 1 ' s Inventory List with Resident 1 ' s Power of Attorney ([POA] legal authorization for a designated person to make decisions about another person ' s property, finances, or medical care), following Resident 1 ' s discharge from the facility on 3/12/2024. This deficient practice resulted in the inability of the facility to determine if Resident 1 ' s belongings were accounted for before giving them to Resident 1 ' s POA and the inability to look for any missing items. This deficient practice had the potential for other residents ' property to be unaccounted for. 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 diagnosis including schizoaffective disorder (combination of two mental illnesses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report Resident 1 ' s debit card was missing to the California Department of Health (CDPH), State Long Term Care Ombudsman (assist residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences) and the local police department (PD) within the regulated time frame of 24 hours for one of three sampled residents (Resident 1). This deficient practice resulted in the delayed investigation of Resident 1 ' s missing debit card, by CPDH, which resulted in 325 unauthorized debit card transactions totaling approximately $11,254.00 from 12/21/2023 through 5/23/2024. 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 diagnosis including schizoaffective disorder (combination of two mental illnesses which include schizophrenia [a mental health condition which causes…

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's Quality Assessment and Assurance ([QAA] develop and implement appropriate plans of action to correct identified quality deficiencies) and Quality Assurance Performance Improvement ([QAPI] takes a systematic, interdisciplinary, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes while involving residents and families, and all nursing home caregivers in practical and creative problem solving) committee failed to identify facility and resident care issues, develop and implement appropriate plans of action to ensure the QAA/QAPI committee systematically implemented and evaluated measures to monitor, review, and analyze data for performance improvement facility issues such as implementing a fall prevention program, that facility staff are educated on, designed to prevent injury from falls, to help prevent the reoccurrence of falls and include person-centered interventions for residents who had a history of falls and/or are assessed as a high fall risk. This deficient…

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 Interdisciplinary ([IDT] Resident ' s health care team members from different specialties working together, with a common purpose, to set goals, make decisions that ensure residents receive the best care) Care Conference meeting following a readmission from a General Acute Care Hospital (GACH), involving one of six sampled residents (Resident 1) and their responsible party (RP), was held. This deficient practice violated Resident 1 and RP 1 ' s right to be an active participant in Resident 1 ' s plan of care and services with the IDT and delayed the discussion of needed care and services. 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 to the facility on [DATE] with diagnoses including epilepsy (a disorder of the brain characterized by repeat seizures [brief episodes of involuntary movement which may include a part 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 a resident, who had physician ' s treatment orders for skin scratches, received the treatment for the scratches, for one of eight sampled residents (Resident 5). This deficient practice resulted in Resident 5 not receiving the treatment as ordered and had a potential for Resident 1 to have further decline in skin integrity due to not receiving the ordered treatment. Findings: During a review of Resident 5 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 5 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of ovary (a type of cancer [disease of the cells (provide structure for the body, take in nutrients from food, convert those nutrients into energy, and carry out specialized functions) in the body] which begins in the ovaries [one of a pair of female reproductive glands in which the eggs are formed]), weakness, and aphasia (inability to communicate with others) with Hospice (medical care that…

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

Based on interview and record review, the facility failed to ensure Certified Nursing Assistant (CNA) 1 who was contracted through a nurse Registry (an agency that provides qualified staffing) to work at the facility, received abuse training and orientation (a one-of event that aims to welcome the employee, help them fit in quickly, and navigate their role and the company) before being assigned resident care. This failure had the potential to result in the inability of the facility to ensure that CNA 1 knew the abuse prevention regulations as mandated by the California Department of Public Health (CDPH) and per their facility ' s policy and procedure (P&P). This deficient practice had the potential to place residents at risk for abuse. Findings: During the review of the facility ' s Report of Suspected Dependent Adult/Elder abuse (SOC 341), dated 12/11/2023, the SOC 341 stated, alleged physical abuse happened on 12/10/2023 at 2:00 a.m. by CNA 1 to a resident. The SOC 341 indicated; the resident had discoloration on the chest on 12/11/2023 at 1:15 p.m. 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.

Based on observation, interview, and record review, the facility failed to ensure all food items stored in one of two kitchen refrigerators were labeled and dated, and the expired food was not stored in the refrigerator. This deficient practice had the potential to result in the residents ingesting expired food and could place residents at risk for foodborne illness (an illness caused by food contaminated with bacteria, viruses, parasites, or toxins) and could lead to symptoms such as nausea, vomiting, stomach cramps and diarrhea. Findings: During the initial tour to the kitchen on 11/27/2023 at 8:31 a.m. Observed juices labeled lemonade in a large pitcher dated 11/15/23 to 11/18/23, Tea labeled 11/23/23, Unlabeled sandwiches in a tray in the refrigerator, Tomato sauce labeled 11/22/23 - 11/26/23. During a concurrent observation and interview on 11/27/2023 at 8:41 a.m. with the dietary aide (DA1) stated the juices are expired and the sandwiches were not labeled, DA1 stated Dietary aide (DA1) stated that she was unable to identify the dates of which the sandwiches were made or when…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement infection control measures by ensuring staff wore the appropriate personal protective equipment (PPE equipment worn to minimize exposure to infections and hazards) prior to entering a contact isolation (a type of infection control for resident's that have infections that are spread by contact) room for 1 of 2 residents (Resident 185). This deficient practice had the potential to spread diseases and infection to other residents, and staff. Findings: During a review of the admission record of Resident 185, the admission record indicated Resident 185 was admitted to the facility on [DATE]. Resident 185's diagnoses included but was not limited to pneumonia (an infection of the lungs), urinary tract (pathway in the human body that makes and removes urine from the body) infection , and Morbid obesity. During a review of the physician order summary dated 11/26/2023, the summary indicated contact isolation due to positive Clostridioides…

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, facility failed to attend to Resident16's need during medication administration by Licensed Vocational Nurse. (LVN1). Resident 16 was provided with a very cold icy water in the morning during medication administration, resident 16 complained about water been very cold for her to take medication, LVN1 stated water is fresh from kitchen and did not address the resident's need and walked away from the room. This deficient practice resulted in Resident 1 shivering, not been able to consume water with medication as desired and freezing with cold. Findings: During a record review of Resident 16's admission Record (Face sheet), the admission record indicated Resident 16 was initially admitted to the facility on [DATE] with diagnosis including urinary tract infection (UTIinfection of the bladder), difficulty walking, major depressive disorder recurrent, (mood disorder that causes a persistent feeling of sadness and loss of interest). During a record review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility failed to provide advance directive to Residents 16 . This deficient practices had the potential for Resident 16's right to refuse or request medical treatment during medical emergencies where resident and family are not available/capable of making decisions. Findings: During a record review of Resident 16's admission Record (Face sheet) indicated the resident was initially admitted to the facility on [DATE] with diagnosis including urinary tract infection (UTI), (infection of the bladder), difficulty walking, major depressive disorder recurrent, (mood disorder that causes a persistent feeling of sadness and loss of interest). During a record review of Resident 16's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 10/20/23, indicated the resident had cognitive (ability to make decisions, understand, learn) impairment, with daily decision making. The MDS assessment indicated the resident required extensive assistance for activities 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, interviews and record review, facility failed to provide : a. a clean urinal with lid cover and toilet bowl with splashes of feces for one of one sampled resident. b. a comfortable temperature environment for resident's room for3 out of 10 sampled rooms had very low temperatures at 66-degree Fahrenheit, These deficient practices resulted in resident's rooms producing bad odors, freezing cold, and uncomfortable for residents staying in the room. Findings: During an initial tour on 11/27/23 at 9:35 a.m. at observed resident rooms with urinals containing urine placed on bed side tables open with no covers toilet bowls with commode, dirty splashes of old feces spread all over the resident's toilet bowl looking old for days not cleaned. During an interview on 11/27/2023 at 9:37 a.m. LVN 5 stated that it was dirty and that it was not right and could cause the room to be very stinky and cross infection for residents. LVN5 stated I will call housekeeping cleaning the rooms, I will empty the urinals…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement fall prevention interventions for one of five sampled residents (Resident 386) who had high risk for falls. This deficient practice had potential to result in falls and serious injury related to fall for Resident 386. Findings: During a record review of Resident 386's admission Record, the admission record indicated Resident 386 was admitted to the facility on [DATE] and last readmitted on [DATE] with diagnoses including hemiplegia (extreme weakness of one side of the body) and hemiparesis (one-sided muscle weakness), seizures (abnormal electrical activity in the brain that happens quickly and may include uncontrollable movements of arms or legs, stiffening and loosening of muscles) and dysphagia (difficulty swallowing). During a record review of Resident 386's history and physical (H&P), the H&P indicated the resident had no capacity to understand and make decisions. During a record review of Resident 386'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement prevent aspiration (inhaling small particles of food or drops of liquid into the lungs) precautions for one of 15 sampled residents (Resident 12), who was receiving nutrition by gastrostomy tube (GT - a flexible tube surgically inserted through the abdomen into the stomach for feeding, fluid, and medication administration), by failing to ensure the resident's head of the bed was elevated during enteral (feeding through stomach) feeding. This failure placed Resident 42 at risk for aspiration that can lead to lung problems such as pneumonia (an infection of the lungs that can cause serious harm) and other complications. Findings: During a review of the admission record, the admission record indicated Resident 42 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included, but not limited to Parkinsonism (progressive disorder that affects the nervous system and the parts 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to honor one of one sample resident (Resident 55)'s meal preference, resulting in Resident 55 getting pancakes when the pancake is listed as one of their dislikes. This deficient practice had the potential to result in weight loss for residents who did not receive the correct food items of their preference. Findings: During a review of Resident 55's Face Sheet (admission record), the Face Sheet indicated Resident 55 was admitted to the facility on [DATE] with diagnosis including Type II Diabetes Mellitus (insufficient production of hormone that regulates blood sugar) without complications, hypertension (high blood pressure), , hypothyroidism (an insufficient production of thyroid hormone that helps regulate body weight, food intake), peripheral vascular disease (narrowing of the arteries that restrict blood supply to the leg muscles), and other disorders of kidney and ureter (muscular tube that carries urine from the kidneys to the bladder:…

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 immediately implement outbreak response measures (acts and procedures to minimize the spread of a disease) when a Coronavirus disease ([COVID-19] a potentially severe respiratory illness caused by a corona virus and characterized by fever, coughing, and shortness of breath) outbreak (when one or more residents who have resided in a skilled nursing facility [SNF] for seven days or more test positive for Covid-19) occurred at the facility on 9/18/2023 for 57of 84 sampled residents. The facility failed to: 1. Ensure a certified nursing assistant (CNA 2) wore a disposable isolation gown and gloves when she was within two feet distance from a COVID-19 positive Resident 1. 2. Ensure CNA 1 doffed (took off) a used N95 Respirator (a respiratory protective device designed to achieve a very close facial fit for effective filtration of airborne particles) after exposure to a COVID-19 positive Resident (Resident 2) and donned (put on) a clean N95 mask…

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 assess the need for and offer the pneumococcal vaccine (a vaccine used to prevent pneumonia [inflammation of the lungs], meningitis [inflammation of the brain] and sepsis [occurs when chemical released in the bloodstream to fight n infection trigger inflammation throughout the body]) for 2 of 5 sampled residents (Residents 2 and 3). This deficient practice resulted in Residents 2 and 3 not being protected against pneumonia and placed them at risk for acquiring pneumonia and transmitting it to other vulnerable residents at the facility. Findings: During a review of Resident 2's admission Record (Face Sheet) the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease with acute exacerbation ([COPD] a group of diseases that cause airflow blockage and breathing-related problems), multiple sclerosis (potentially disabling disease of the brain and spinal cord ) cardiomegaly…

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 out of three sampled resident's, (Resident 1) adult disposable brief was checked against her will. This deficient practice resulted in Resident 1 feeling violated, humiliated and unsafe. Findings: During a review Resident 1's admission record, dated 9/26/2023, the admission record indicated, Resident 1 was admitted on [DATE] with a diagnosis including hemiplegia (one sided muscle paralysis or weakness) and hemiparesis (inability to move on one side of the body) following cerebral infarction (disrupted blood flow to the brain), dependence on renal dialysis (treatment for the kidneys to remove waste products and excess fluid from the blood), and muscle weakness. During a review of Resident 1's Minimum Data Set (MDS- a standardized assessment and care screening tool), dated 9/1/2023, the MDS indicated, Resident 1's cognition was intact, and the resident had the ability to be understood by others and understand others. 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 interview and record review, the facility failed to implement their abuse reporting policy by not reporting allegations of physical abuse to the California Department of Public Health (CDPH) in a timely manner for one out of three sampled residents, Resident 1. This deficient practice had the potential for the underreporting of abuse incidents and a delay in investigation of abuse allegations, placing Resident 1 at risk for further abuse. Findings: During a review Resident 1's admission record, dated 9/26/2023, the admission record indicated Resident 1 was admitted on [DATE] with a diagnosis including hemiplegia (one sided muscle paralysis or weakness) and hemiparesis (inability to move on one side of the body) following cerebral infarction (disrupted blood flow to the brain), dependence on renal dialysis (treatment for the kidneys to remove waste products and excess fluid from the blood), and muscle weakness. During a review of Resident 1's Minimum Data Set (MDS- a standardized assessment and care…

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