Intercommunity Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of six sampled residents (Resident 130)'s: informed consent for Zyprexa [medication used to treat schizophrenia (a mental illness that is characterized by disturbances in thought) or bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs)] included the manifested behavior for the medication indication useInformed consent for Remeron (medication used to treat major depressive disorder) was renewed every six months. This deficient practice had the potential to violate the residents' right to make an informed decision regarding the use of psychotropic medications. Findings: During a review of Resident 130's admission Records, the admission Records indicated the facility admitted Resident 130 on 2/26/2021 and was readmitted on [DATE] with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought) and resting…

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 and accommodate the resident's food preferences in a timely manner for one of four sampled residents (Resident 106). This deficient practice had the potential to negatively impact the resident's nutritional status, appetite, autonomy, and overall well-being. Findings:During a review of Resident 106's admission Record, the admission Record indicated Resident 106 was readmitted to the facility on [DATE] with diagnoses including paranoid schizophrenia (a mental illness that is characterized by intense irrational suspicions), Type II Diabetes Mellitus (DM, a chronic disease that affects how the body processes sugar), and anemia (a condition where the body does not have enough healthy red blood cells).During a review of Resident 106's history and physical (H&P) dated 4/11/2026, the H&P indicated Resident 106 has fluctuating capacity to understand and make decisions. During a review of Resident 106'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 complete a change of condition and notify the physician when:a. one of 28 sampled residents (Resident 80) had a significant change in physical status identified in 4/2026 when multiple Restorative Nursing Aide (RNA, nursing aide program that help residents to maintain their function and joint mobility) staff reported Resident 80's repeated refusals to wear splints (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) and attempts to take off splints.b. Resident 122 started to pull their front wheel walker (FWW - type of mobility aid with wide base of support) behind them when walking instead of pushing the FWW in front of their body.These deficient practices resulted in Resident 80 experiencing a decline in range of motion (ROM, full movement potential of a joint) in the knees and ankles without facility physician's knowledge and providing alternative interventions and treatments and the potential to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure three out of three sampled residents (Resident 150, Resident 160, and Resident 170) were provided privacy when Resident 144 was observed going into their room and using the restroom without permission. This deficient practice had the potential to violate the resident's rights and right to privacy. Findings: a. During a review of Resident 150's admission Record, the admission Record indicated Resident 150 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease (CKD, a long-term condition where the kidneys are damaged and gradually lose their ability to filter waste and excess fluid from the blood), heart failure (a chronic condition where the heart muscle doesn't pump blood as efficiently as it should, preventing it from meeting the body's needs), and urinary retention (the inability to completely empty your bladder, or not being able to urinate at all). During a review of Resident 150's minimum data…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe, comfortable, and homelike environment when the facility failed to:1. Provide Resident 12 with a pillow. 2. Provide Resident 88 with a pillow. 3. Ensure one out of 8 sampled residents (Resident 100) did not have peeling paint in their restroom. These deficient practices placed Residents 12, 88, and 100 at risk of not experiencing the facility as their home, and placed Residents 12 and 88 at risk of discomfort while resting in bed Findings: 1. During a review of Resident 12's admission Record, The admission Record indicated the facility initially admitted Resident 12 on 12/2/2021 and readmitted on [DATE] with diagnoses including metabolic encephalopathy (any damage or disease that affects the brain), muscle wasting and atrophy (decrease in muscle mass). During a review of Resident 12's Minimum Data Set (MDS, resident assessment tool) dated 2/2/2026, the MDS indicated Resident 12 had severe cognitive (mental processes…

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 146) by failing to: Ensure there was an informed consent form prior to the abdominal binder (a soft band made of stretchy soft material that wraps around the stomach). being on Resident 146.Completed a physical restraint assessment. Initiated an abdominal binder care plan.Monitor the use of an abdominal binder. These deficient practices had the potential to result in injury and inhibit the residents' freedom of movement or activity.FindingsDuring a review of Resident 146's admission Record, the admission Record indicated Resident 146 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), gastrostomy (g-tube, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and dementia (a progressive state of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the resident's fingernails were kept trimmed and clean to prevent skin excoriation (a scrape or scratch to the skin) caused by scratching for one of seven sampled residents (Resident 115).This failure had the potential to result in further skin injuries and infection for Resident 115.Findings:During a review of Resident 115's admission record, the admission record indicated Resident 115 was initially admitted to the facility on [DATE] and last readmission was on 5/27/2025 with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), skin-picking disorder(a mental health condition characterized by the repeated, compulsive picking of one's own skin) and dementia (a progressive state of decline in mental abilities).During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to monitor one of three sampled resident's (Resident 40) eyes as ordered by the physician. This deficient practice had the potential for a delay of care to occur for Resident 40. Findings: During a review of Resident 40's admission Record, the admission Record indicated Resident 40 was admitted to the facility on [DATE] with diagnoses including glaucoma (a group of eye diseases that damage the optic nerve caused by a buildup of fluid and elevated pressure inside the eye), Type II Diabetes Mellitus (DM, a chronic disease that affects how the body processes sugar), and frontotemporal neurocognitive disorder (rare progressive brain disease caused by the damage and shrinking of the brain's frontal [behind the forehead drives movement and personality] and temporal [near ears that process memory, language, and auditory information] lobes. During a review of Resident 40's Minimum Data Set (MDS, a resident assessment tool), dated 2/7/2026, the MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide services and treatments to maintain or prevent further decline in joint range of motion (ROM, full movement potential in a joint) in two of 28 sampled residents (Residents 80 and 36) when the facility failed to:1. Provide Resident 80 Physical Therapy (PT, a rehabilitation profession that restores, maintains, and promotes optimal physical function) treatments to assess and establish a safe wear time for new ankle splints (rigid material or apparatus used to support and immobilize a broken bone or impaired joint).2a. Objectively measure Resident 36's ROM impairments in the left hand during an Occupational Therapy (OT, rehabilitative profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) evaluation dated 12/8/2025.2b. Assess Resident 36 and establish a safe wear time for a new left hand splint during occupational therapy treatments.2c. Document a safe wear time…

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 Identify and to intervene on events in one of three sampled residents (Resident 59)' history of trauma and triggers which may cause re-traumatization (a person encounters a new event or stimulus that triggers them to re-experience the intense stress, emotional distress, and even flashbacks of a previous traumatic event as if it were happening again).This failure had the potential to result in Resident 59 experiencing re-traumatization, and a declining quality of life.Findings:A. During a review of Resident 59's admission record, the admission record indicated Resident 59 was admitted initially to the facility on 9/25/2023 and last readmission was on 1/27/2025 with diagnoses including PTSD, depression (a mental health condition marked by a prolonged low mood and a loss of interest or pleasure in everyday activities), insomnia (trouble falling asleep or staying asleep), and left eye blindness.During a review of Resident 59's History and Physical (H&P), dated 10/11/2025, the H&P indicated, Resident 59 had the capacity…

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

Based on interview and record review, the facility failed to ensure two of five Certified Nursing Assistants (CNA) had an annual performance evaluation. This failure had the potential to result in staff performing duties without adequate assessment of their competency, knowledge, and job performance leading to errors in resident care, failure to identify training needs, and decreased quality of care.Findings:During a concurrent interview and record review on 6/11/2026 at 9:12 a.m., with the Director of Staff Development (DSD), CNA 9 and CNA 10's employee files were reviewed. The DSD stated CNA 9 and CNA 10 did not have annual performance evaluations. During an interview on 6/12/2026 at 8:59 a.m., with the DSD, the DSD stated the importance of making sure annual performance evaluations were conducted was to ensure staff were evaluated on their knowledge and skills to care for the facility's resident population. The DSD stated if annual performance evaluations were not conducted, the facility would be unable to determine whether the staff was competent and has the knowledge regarding…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure one of four sampled residents (Resident 146)'s prescribed midodrine (medication used to treat low blood pressure) was available to administer, after the last dose was administered on 6/7/2026.This failure resulted in Resident 146 not receiving the prescribed midodrine and had the potential to result in delayed treatment of hypotension (low blood pressure), decreased perfusion (blood flow) to vital organs, and the need for additional medical interventions.Findings:During a review of Resident 146's admission Record, the admission Record indicated Resident 146 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and dementia (a progressive state of decline in mental…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of four residents (Resident 146) was free from significant medication error (any preventable error in medication administration that can result in resident discomfort, jeopardizing health and safety, or requiring medical intervention) by failing to:1. Ensure the physician was notified when Resident 146's prescribed midodrine (medication used to treat low blood pressure) was unavailable for administration 2. Ensure the physician was notified when Resident 146 subsequently experienced an episode of low blood pressure.This failure resulted in a significant medication error by not administering the medication as ordered by the physician and had the potential for Resident 146's increased risk for adverse effects of low blood pressure.Findings:During a review of Resident 146's admission Record, the admission Record indicated Resident 146 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease (a disease…

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 maintain accurate and complete medical records for two of 28 sampled residents (Resident 36 and 146) when the facility failed to:1. Sign Resident 36's Joint Mobility Assessments (JMA, assessment of joint range of motion [ROM, full movement potential of a joint] to monitor changes) dated 9/25/2025 and 12/22/2025.2. Ensure accurate medication administration and documentation by signing the Medication Administration Record (MAR) to reflect Resident 146 did not receive the prescribed midodrine (medication used to treat low blood pressure) when the medication was not available and was not administered.These deficient practices resulted in inaccurate and incomplete medical records for Residents 36 and 146. Findings: 1. During a review of Resident 36's admission Record, the admission Record indicated the facility initially admitted Resident 36 to the facility on 9/15/2023 and readmitted on [DATE] with diagnoses including, schizoaffective disorder…

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 implement infection control measures by not ensuring that the padded side rails and bed frames wrapped with porous (having minute spaces or holes through which liquid or air may pass) foam were properly disinfected for one of seven sampled residents (Resident 49).This failure had the potential to result in compromised infection control measures to prevent the spread of infection among residents, staff, and visitors.Findings:During a review of Resident 49's admission record, the admission record indicated Resident 49 initially admitted Resident 49 on 4/9/2024 and last re-admission was on 2/15/2026 with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought), anxiety disorder (constantly feeling worried and nervous), and bradycardia (a resting heart rate that is abnormally slow, typically falling below 60 beats per minute).During a review of Resident 49's History and Physical (H&P), dated 4/23/2026, the H&P indicated, Resident 49 did not have the capacity (ability)…

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 implement its antibiotic stewardship program [the effort to ensure that antibiotics (medicines that fight bacterial infections in people) are used only when necessary and appropriate] for one of three sampled residents (Resident 115) by not identifying the indication and duration of the prescribed antibiotic and not assessing the resident using Loeb's Minimum Criteria (a set of standardized guidelines designed primarily for long-term care facilities to prevent the overuse of antibiotics).This failure had the potential to result in Resident 115 developing antibiotic resistance (the ability of bacteria to change and survive the effects of antibiotics designed to kill or stop them), increasing the risk that Resident 115 could receive unnecessary or inappropriate antibiotic therapy.Findings:During a review of Resident 115's admission record, the admission record indicated the facility initially admitted Resident 115 to the facility on 7/1/2024 and last readmission was on 5/27/2025 with diagnoses including…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide two of 28 sampled residents (Residents 12 and 80) with safe resident care equipment when:1. Resident 12's floor mat was torn and did not extend the full length of Resident 12's bed.2. Resident 80's wheelchair armrests were torn, and the padding underneath was exposed and Resident 80's pommel cushion (wheelchair cushion with raised middle portion for positioning) had duct tape taped around the middle raised portion and the foam inside was exposed.These failures had the potential to cause injury if Resident 12 fell off the bed and cause Resident 80 skin irritation and excoriation (scrape or scratch to the skin) when the skin rubbed against the duct tape and torn wheelchair cushion materials. Findings:1. During a review of Resident 12's admission Record, the admission Record indicated the facility initially admitted Resident 12 on 12/2/2021 and readmitted on [DATE] with diagnoses including, but not limited to metabolic encephalopathy…

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 an injury of unknown origin to the California Department of Public Health (CDPH), when one of three sampled residents (Resident 1) was found on the floor in his room, face down and unresponsive requiring CPR and who subsequently expired at the facility on [DATE] This deficient practice resulted in the CDPH being unaware of Resident 1's injury and the inability of the CDPH to conduct a timely investigation which hindered their efforts to determine the cause of the incident (e.g., fall, assault, or medical event). This deficient practice had the potential for information related to the investigation to be lost and/or forgotten 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 diagnoses that included, schizophrenia (mental illness that is characterized by disturbances in thought), glaucoma (a group of eye…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that the resident received treatment and care in accordance with professional standards of practice for one of three sampled residents (Resident 1) by failing to ensure Certified Nurse Assistant (CNA)1 placed the foot pedals (also known as foot rests- designed to provide postural support and stability as well as distribute weight bearing during sitting or transporting) before transporting Resident 1 to the dining room for lunch via wheelchair.This failure resulted in Resident 1 wearing non-skid shocks (also known as non-slip or gripper socks, are socks with textured or rubberized soles designed to increase traction and prevent slipping on smooth surfaces) being thrust out from wheelchair due to friction (the resistance that one surface or object encounters when moving over another) while CNA 1 was pushing the wheelchair. Resident 1 sustained small cut on mid forehead and a superficial abrasion (a superficial wound caused by 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 implement infection control measures by failing to: A. Ensure implementing Enhanced Barrier Precaution (EBP- an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities) for Resident 54 who had gastrostomy tube (G-tube-a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) placed. B. Implement the water management plan (comprehensive plan aimed at preventing waterborne illnesses by controlling germs in the water). C. Implement EBP interventions when Licensed Vocational Nurse 1 (LVN) 1 provided direct care for Resident 119. D. Perform hand hygiene between Resident care for Resident 77, Resident 90 and Resident 137. E. Ensure Maintenance/ Laundry ML staff (ML) did not let clean sheets touching the floor while folding them. F. Ensure ML used…

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 protection and promotion of resident rights for two of two sampled residents (Resident 22 and Resident 89) by: a. Not providing eye level positioning while assisting Resident 89 with eating. b. Not ensuring privacy curtain was closed exposing Resident 22's left buttock . These deficient practices resulted in residents not being treated with dignity and respect, and not receiving care in a manner that promotes quality of life. Findings: a. During a review of Resident 89's admission Record, the admission Record indicated, the facility admitted Resident 89 on 7/22/2016 and readmitted on [DATE] with diagnoses including schizoaffective disorder (a mental health condition where a person experiences symptoms of both schizophrenia [a chronic mental illness that causes a break with reality] and a mood disorder) and iron deficiency anemia (a condition where the body does not have enough iron to produce healthy red blood cells). During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement person centered care plans ( (a document that outlines a resident's care needs, diagnosis, and treatment goals) for five out of five sampled residents (Resident 95,120,396, 93 and 5), by failing to: A.Implement care plan interventions for elopement risk for Resident 95. B.Implement a comprehensive care plan for Resident 120 who had a diagnosis of post-traumatic stress disorder ([PTSD], a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event). C. Develop a baseline smoking care plan for Resident 93, Resident 396, and Resident 5 who smoke. These deficient practices had the potential for the residents' care needs not to be addressed and the lack of ability to identify the residents' ongoing needs. Findings: During a review of Resident 95's admission Record, the admission Record indicated, Resident 95 was admitted to the facility on [DATE] with diagnoses including…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow proper sanitation and food handling practices by: 1.Failing to label open bag of pancake mix with an open date. 2.Failing to place a lid on an open container of breadcrumbs 3.Failing to close the lid on macaroni noodles and egg noodles 4.[NAME] to clean stationery can opener when it was found with a black tarry substance on it. These deficient practices had the potential to result in using pancake mix beyond its expiration date causing vulnerable residents to get sick. Pests, dust and other airborne particles that can contaminate the food items, and a potential for food contamination from the tarry substance on the can opener. During an initial observation of the kitchen on 5/5/2025 at 8:10 a.m., with the Dietary [NAME] (DC) 1 in the dry food area, on the shelf there was one bag of opened buttermilk pancake mix and no open date. On another shelf there was one large plastic container of breadcrumbs with no lid, one large container 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 two of five sampled residents' (Resident 91 and 96) pneumococcal vaccination (medication that helps protect against serious illnesses like pneumonia [lung infection]) status was documented in Resident 91 and 96's medical records. This deficient practice had the potential to result in inaccurate depiction of resident health status. Findings: During a review of Resident 91's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 91 was admitted to the facility on [DATE], with the diagnoses including dementia (a progressive state of decline in mental abilities) and diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 91's Minimum Data Set (MDS), a resident assessment tool, dated 2/21/2025, the MDS indicated Resident 91's cognition was severely impaired and the MDS indicated Resident 91 needed…

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 160 of 160 facility staff were educated on Enhanced barrier Precautions (EBP - involve gown and glove use during high-contact resident care activities). This deficient practice had the potential to result in increased risk of cross contamination (the physical movement or transfer of harmful germs from one person, object or place to another). Findings: During a review of Resident 119's Face Sheet, the face sheet indicated the facility originally admitted Resident 119 on 11/22/2021 with a diagnosis including gastrostomy (G-Tube - 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 119's Minimum Data set (MDS), a resident assessment tool, dated 3/31/2025, the MDS indicated the resident's cognition was severely impaired. The MDS indicated Resident 119 was dependent on staff with all activities of daily living (ADLs- activities such as bathing, dressing and toileting a person…

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 obtain a completed psychotropic medication (drugs that are used to treat a variety of mental health conditions) consent (a document that legally and ethically records an individual's agreement to participate in a specific treatment, ensuring they understand the potential risks and benefits involved) for one of six sampled residents (Resident 119). This failure had the potential for escalation of symptoms due to delay or failure initiating needed treatment due to lack of consent and can lead to worsening psychiatric (relating to mental illness) symptoms. Findings: During an interview on 5/5/25 at 12:38 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated psychotropic medication consents need the name of the resident, medication, dosage, route and signed by the doctor. During an interview on 5/5/25 at 12:40 p.m. with LVN 2, LVN 2 stated psychotropic medication consents need to have the resident name, medication, dose, route, and frequency. During an interview on 5/8/25 at 11:03 a.m. with Registered Nurse (RN) 1, RN 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, record review, the facility failed to ensure the call light was within reach for one of six sampled residents (Resident 94). This failure had the potential for increased risk of falls, delayed response to emergencies, and unmet basic needs of Resident 94. Findings: During a concurrent observation and interview on 5/5/25 at 9:27 a.m. with Activities Aide (AA) 1, in Resident 94's room, Resident 94 was asleep in bed with the call light on the floor behind the dresser. AA 1 stated the call light was not within reach but should have been within reach. During an interview on 5/5/25 at 11:08 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated the call light should be within reach. LVN 1 stated if call light is not within reach it can lead to falls. During an interview on 5/6/25 at 9:54 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated the call light should be in resident's reach. CNA 1 stated anything can happen like falls if needs are not met . 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 less restrictive restraints (to limit, restrict, or keep under control) before the use of a Geri-chair (a specialized large, padded chair with wheeled base to enable transport, designed to recline and to assist residents with limited mobility) with a lap tray (a detachable tray that attaches to most chairs) and provide ongoing monitoring for the continued use of the restraint to keep one of two sampled residents from falling (Resident 134). This deficient practice had the potential to place Resident 134 at risk for decline in physical functioning, and potential for unwanted behaviors when there was no monitoring for continued use of the lap tray. Findings: During a review of Resident 134's admission Record, the admission Record indicated Resident 134 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), anxiety (a feeling of fear, dread, 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 accurately complete the minimum data set (MDS - a resident assessment tool) assessment Section I (active diagnoses), dated 3/10/25, by failing to include a diagnosis of schizophrenia (a mental illness characterized by hearing or seeing things that are not there) per information in the medical record for one of five residents sampled for unnecessary medications (Resident 92.) This deficient practice of failing to accurately assess active diagnoses and complete MDS Section I increased the risk that Resident 92 may not have received care planning and treatment according to his needs possibly leading to a decline in his overall health and well-being. Findings: During a review of Resident 92's admission Record (a record containing diagnostic and demographic resident information), dated 5/7/25, indicated he was admitted to the facility on [DATE] with diagnoses including schizophrenia. During a review of Resident 92's History and Physical (H&P - a record 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to complete the Preadmission Screening and Resident Review (PASARR - resident screening to ensure those with severe mental illness or intellectual disability are receiving services according to their needs) Level 1 for one of three sampled residents (Resident 40) pre admission or soon there after. This deficient practice had the potential to result in an inappropriate placement and delay of the residents' needed services. Findings: During a review of Resident 40's admission Record, the admission Record indicated Resident 40 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought), chronic obstructive pulmonary disease ([COPD], a chronic lung disease causing difficulty in breathing), hypertension ([HTN], high blood pressure). During a review of Resident 40's History and Physical (H/P), dated 3/4/2025, the H/P indicated Resident 40…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide treatments and services to improve, prevent and/or limit a decline in joint (where two bones meet) range of motion (ROM, full movement potential of a joint) to one of eight sampled residents (Resident 109) who was identified as having ROM limitations in the right hand, right wrist, and left ankle. This deficient practice had the potential to cause Resident 109 to have a decline in ROM leading to contractures (loss of motion of a joint associated with stiffness and joint deformity) and have a decline in physical functioning such as the ability to eat, dress, and walk. Findings: During a review of Resident 109's admission Record, the admission Record indicated Resident 109 was admitted to the facility on [DATE] with diagnoses including muscle weakness, chronic fracture (broken bone) and osteomyelitis (bone infection) of the left tibia (one of the bones of the leg that connects the knee to the ankle joint) and left fibula (smaller 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 monitor and document hourly rounds to prevent elopement (an unauthorized departure of a patient from an around-the-clock care setting without the facility's knowledge and supervision) for one of three sampled residents (Resident 95) who was at risk for elopement. This failure had the potential to result in Resident 95 potentially eloping the facility and being put at risk for accidental injury or death. Findings: During a review of Resident 95's admission Record, the admission Record indicated, Resident 95 was admitted to the facility on [DATE] with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), alcohol dependence, and heart failure (a lifelong condition in which the heart muscle can't pump enough blood to meet the body's needs for blood and oxygen). During a review of Resident 95's History and Physical (H&P), dated 9/26/2024, the H&P indicated,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 49)'s nasal cannula was labeled with a date to ensure it was changed timely. This failure had the potential to place Resident 49 at risk of infections and health complications due to use of the same nasal cannula for an unknown prolonged period of time Findings: During a review of Resident 31's admission Record, the admission Record indicated, the facility admitted Resident 31 on 2/18/2018 and readmitted on [DATE] with diagnoses including acute respiratory failure (your lungs are struggling to get enough oxygen into your blood or to remove enough carbon dioxide, leading to serious problems with your body's functions) and Chronic Obstructive Pulmonary Disease (COPD-a lung disease that makes it difficult to breath). During a review of Resident31's Minimum Date Set (MDS-a resident assessment tool), dated 3/31/2025, the MDS indicated Resident 31's cognitive skills for daily decision making were…

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 120), who was diagnosed with post-traumatic stress disorder ([PTSD], a mental health condition that can develop after someone experiences or witnesses a traumatic event), received trauma informed care (a model that aims to provide effective mental health services by taking into account a person's past experiences with trauma). This deficient practice had the potential to result in Resident 120's re-traumatization and can be detrimental for the resident's psychosocial well being. Findings: During a review of Resident 120's admission Record, the admission Record indicated Resident 120 was originally admitted on [DATE] with a re-admission date of 1/27/2025 with diagnoses including depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), diabetes mellitus ([DM]-a disorder characterized by difficulty in blood sugar control and poor wound healing), dementia (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure staff were in-serviced (educated) for post-traumatic stress disorder ([PTSD], a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event) and trauma informed care for one of three sampled residents (Resident 120) who had a diagnosis of PTSD. This deficient practice had the potential to negatively affect all residents that reside in the facility with diagnosis of PTSD due to staff not being aware of and how to care for the residents with PTSD. Findings: During a review of Resident 120's admission Record, the admission Record indicated Resident 120 was originally admitted on [DATE] with a re-admission date of 1/27/2025 with diagnoses including depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), diabetes mellitus ([DM]-a 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 observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%). Two medication errors out of 26 total opportunities contributed to an overall medication error rate of 7.69 % affecting one of four residents observed for medication administration (Resident 21.) The medication errors noted were as follows: 1. Attempted early administration of multivitamin (a vitamin supplement) 2. Attempted early administration of vitamin D (a vitamin supplement) These deficient practices of failing to administer medications in accordance with the physician's orders increased the risk that Resident 21 may have experienced medical complications possibly resulting in hospitalization. Findings: During a review of Resident 21's admission Record (a document containing diagnostic and demographic information), dated 5/7/25, indicated he was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia (a mental illness characterized by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to: 1. Label one opened vial of Humulin R (a type of insulin used to control blood sugar) with an open date affecting Resident 6 in one of three inspected medication carts (Station A Medication Cart.) 2. Remove one expired vial of Humulin R opened on [DATE] from the medication cart affecting Resident 104 in one of three inspected medication carts (Station A Medication Cart.) These deficient practices of failing to store or label medications per the manufacturers' requirements increased the risk that Residents 6 and 104 could have received medication that had become ineffective or toxic due to improper storage possibly leading to health complications resulting in hospitalization or death. Findings: During a concurrent observation and interview on [DATE] at 11:45 AM of Station A Medication Cart with the Licensed Vocational Nurse (LVN 1), the following medications were found either expired, stored in a manner contrary to their respective…

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 provide documented evidence of all employees screening, education, offering, and current Corona virus disease, COVID-19 (contagious infectious disease), vaccination (medications used to prevent diseases usually given by injection or by mouth) status. This failure had the potential to place staff and residents at risk for serious outcomes such as being hospitalized due to COVID-19. Findings: During a concurrent interview on 5/7/2025 at 10:07 a.m. with the Infection Prevention Nurse (IPN), and record review of the facility's employee records of COVID-19 status 2024 to 2025 for physicians, consultants, and Rehabilitation Staffs' COVID-19 immunization status were unknown. There was no documented evidence that the physicians, consultants, and rehabilitation staff were screened, educated, and offered current Covid-19 vaccination. The IPN stated she did not get the physicians and consultants and Rehabilitation Staffs' Covid-19 immunization status. During a review of the facility's policy and procedure (P&P) titled, Covid-19…

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 an injury of unknown origin for one of three sampled residents (Resident 1), when Resident 1 had an unwitnessed fall and sustained a left hip fracture (a break in the bone). This deficient practice resulted in the inability of the California Department of Public Health (CDPH) to investigate Resident 1's injury in a timely manner and had the potential for information to be lost and/or forgotten. 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 diagnoses including displaced intertrochanteric fracture of right femur (a break in the hip bone), displaced intertrochanteric fracture of the left femur, difficulty walking, and dementia During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 1/10/2025, the MDS indicated Resident 1 was severely cognitively impaired and exhibited…

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 residents have the right to be free from abuse for one of two sampled residents (Resident 1). This deficient practice resulted in Resident 2 slapping Resident 1 on the left cheek, potential placing Resident 1 to feel unprotected and other residents at risk of further abuse. a. 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 with diagnoses including dementia (a progressive state of decline in mental abilities), psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), any anxiety disorder (uncontrollable worry and fear about everyday situations). During a review of Resident 1 ' s History and Physical (H&P) dated 1/11/2025, the H&P indicated Resident 1 does not have the capacity to understand and make decisions. During a review of Resident 1 ' s Minimum Data Set [(MDS) a standardized…

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 three out of 31 facility staff had an active Certified Nursing Assistant (CNA) certificate before providing direct resident care. This deficient practice had the potential to compromise residents safety as the uncertified staff may not be qualified to perform their duties. During a review of the December 2024 CNA monthly staff schedule, the monthly staff schedule indicated CNA 3 was scheduled to provide direct resident care. During a review of the Certificate Verification database (official site to verify certificate status for CNAs) for Certified Nursing Assistant 3 (CNA 3), the search page indicated there were no data found with CNA 3's certification status information. During a review of the December 2024 CNA monthly staff schedule, the CNA monthly staff schedule indicated CNA 4 was scheduled to provide direct resident care. During a review of the CNA Certificate Verification database for CNA 4, the search page indicated there were no data found with CNA 4's certification status. During a review of the December…

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 the night shift staffs were being in serviced (staff education) for the same subjects as the day and evening shifts. This failure had the potential to jeopardize the safety of residents when staff members are not adequately educated. During an interview on 12/23/2024 at 3:56p.m. with the Director of Staff Development (DSD), the DSD stated she does the in services and come at different times to cover all of the shifts. DSD stated in services are done monthly, when there is an incident, or as needed. DSD stated for showers, it is on their assignments and is a part of their daily task for 7:00a.m. to 3:00p.m. (day) shift and 3:00p.m. to 11:00p.m. (evening) shifts, so the 11:00p.m. to 7:00a.m. (night) shift does not have to have an in service for showers since they do not give showers at night. During a concurrent interview and record review of the in service on 12/23/2024 at 4:12p.m. with the DSD, the DSD stated the in service dated 10/2/2024: Cell phone policy was done as there was a complaint about the staff using…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assess, monitor, and document restraint monitoring flow sheet for three of three sampled residents (Resident 1, 2 and 3). This failure had the potential to result in siderail entrapment (occurs when a resident is trapped between a bed rail and the mattress, or within the rail itself),skin injury, accident, and compromised circulation. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated, Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), Alzheimer ' s disease (a disease characterized by a progressive decline in mental abilities), and nose fracture (broken bone). During a review of Resident 1 ' s History and Physical (H&P), dated 4/13/2024, the H&P indicated, Resident 1 had no capacity (ability) to understand and make decision. During a review of Resident 1 ' s Minimum Data Set…

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

Based on observation, interview and record review, the facility failed to ensure six out of six nurse aides successfully completed a nurse aide training and competency evaluation program. before allowing the nursing aides to provide direct resident care without supervision. This deficient practice had a potential for residents not getting appropriate care due to lack of training. Findings. During a review of the 7 a.m. to 3 p.m., daily assignment sheet dated 11/20/2024 indicated that Nursing Assistant (NA) 1 assignment was for Rooms 9-11. During a review of the 7 a.m. to 3 p.m. daily assignment sheet dated 11/19/2024 indicated that NA 1 assignment was for Rooms 6-8. During a review of the 7 a.m. to 3 p.m. daily assignment sheet dated 11/12/2024 indicated that NA 1 assignment was for Rooms 30-34. During a review of the 3 p.m. to 11 p.m. daily assignment sheet dated 11/18/2024 indicated that NA 2 assignment was for Rooms 30-34. During a review of the 3 p.m. to 11 p.m. daily assignment sheet dated 11/16/2024 indicated that NA 2 assignment was for Rooms 11-17. During a review of the 3…

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 the required in service training will be conducted upon hire and annually per facility ' s Policy and Procedure (P&P) titled Competency of Nursing Staff dated 5/2019. The facility failed to: a. Ensure sexual harassment or LGBQT (acronym for lesbian, gay, bisexual, transgender and queer) training was provided to Nurse aide (NA) b. Ensure required hours of dementia (progressive state of decline in mental abilities) training were provided upon hire and annually. c. Ensure abuse training was provided for NA1, NA3, NA6. d. Ensure Director of Staff Development have lesson plans (guide that outlines what staff will learn, how it will be taught, and how learning will be assessed) for abuse or infection control in-service training. Abuse mandated reporter in-service dated 5/3/2024 and 8/29/2024- no lesson plan. Abuse (Different Types) in-service dated, 5/3/24 – no lesson plan. Infection Control in-service dated 11/6/24 – no lesson plan. These failures had the potential to jeopardize the safety of residents when staff members…

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 1 2 and Resident) were monitored during a smoking break while on the facility's patio by the appropriate number of staff in order to prevent a physical altercation between Resident 1 and Resident 2. This deficient practice resulted in a fracture to Resident 1's nose and Resident 1's transfer to a General Acute Care Hospital (GACH) where Resident 1 underwent a reduction (realignment of bones) of her nasal bones, and compression with rightward pressure to repair/straighten her nasal deviation. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including dementia (loss of thinking, remembering, reasoning), bipolar disorder (mental disorder that causes a shift in mood and behavior) and schizophrenia ( mental disorder that affects how someone thinks, feels,…

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 a physical altercation between two of three sampled residents (Resident 1 and Resident 2), to the California Department of Public Health (CDPH), within two hours of the incident. On 8/18/2024 at approximately 8 a.m., facility staff witnessed Resident 2 elbow Resident 1 in her nose, resulting in Resident 1 sustaining a bloody nose, ecchymosis (bruising) to her nose and a nasal deviation (shifted to one side). The facility reported the incident on 8/18/2024 at 11:55 p.m., (approximately 16 hours after the incident occurred). This deficient practice resulted in CDPH being unaware of the abuse incident and injury to Resident 1 and had the potential for a delay in CDPH's investigation and other abuse allegations to go unreported. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including dementia (loss…

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's Quality Assessment and Assurance committee ([QAA] a group of facility staff who identifies, evaluates, and implements measures to improve the quality of care and life for the residents in the facility) and Quality Assurance Performance Improvement ([QAPI] a group who takes a systemic, 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 ensure continued oversight of the facility's plan of correction (POC) of the deficient practices identified during the previous abbreviated survey (5/28/2024) pertaining to abuse prevention and reporting. This deficient practice resulted in the facility having another occurrence of resident-to-resident altercation resulting in physical injury to Resident 1 and the facility's failure to report the incident to the Department 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 STAT (immediate or urgent) X-ray (a medical procedure that creates pictures of the structures of the inside of the body) was ordered immediately for one of three sampled residents (Resident 1), when Resident 1 was assessed with swelling above her right knee and right posterior (back of) thigh, following a popping sound that was heard when Resident 1 was transferred from a Geri-chair (a large, padded chair that is designed to help seniors with limited mobility) to a bed. The facility failed to: Follow when STAT X-ray was ordered, and the physician did not return the call, when the STAT X-ray was eventually ordered, and the X-ray technician did not arrive to the facility in a timely manner, and when the STAT X-ray was taken and the results of the STAT X-ray was not received timely. This deficient practice resulted in a delay in evaluation and transfer of Resident 1 to the General Acute Care Hospital (GACH), when STAT X-ray results 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 record review and interview, the facility failed to provide evidence that a thorough investigation of a resident-to-resident altercation between two of two sampled residents (Resident 1 and 2) was conducted or that a five-day summary was sent to the California Department of Public Health (CDPH). This deficient practice resulted in the allegation of abuse by Resident 1 against Resident 2 not being thoroughly investigated and the conclusion of the facility's investigation not being known by CDPH. This deficient practice had the potential to result in unidentified abuse in the facility and failure to protect residents from abuse. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including unspecified dementia (impaired ability to remember, think, or make decisions). 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.

Based on observation, interviews, and record review the facility failed to follow kitchen hygiene, handling, and storage of food products in the kitchen. a. By not dating an opened food items. b. Storing uncooked opened bag of raw fish on top of other raw meats in the refrigerator. These deficient practices had the potential to cause food borne diseases in the facility residents who depend on facility prepared food for daily feeding and contaminate other food stored in the refrigerator. Findings: During an initial kitchen observation on 05/07/24 at 10:35 a.m., open salmon fillet out of the box with no open date was placed on top of the pork box inside the refrigerator Dietary Supervisor stated it was opened and should not be placed at the refrigerator. During an interview on 05/09/24 at 09:34 A.M., with the Dietary supervisor (DS), DS stated I don't know how they got up there the opened salmon should be wrapped up and kept at the bottom of the refrigerator. DS stated when kitchen staff opens it they are supposed to put a date and wrap it up so everyone knows. It should be kept in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview , and record review, the facility failed to ensure three of five sampled residents ( Resident 8, 58 and 69 ) were free of unnecessary physical restraints (any object or device that an individual cannot remove easily which restricts freedom of movement) by failing to: 1.Ensure on-going assessment and reevaluation of restraints' continuous use were conducted and documented. This failure had the potential to place Resident 8, 58 and 69 at risk for unnecessary prolonged use of restraints , impaired blood circulation, skin injuries and entrapment ( an event in which a patient is caught, trapped , or entangled). Findings: During a record review of Resident 8's Face Sheet (document containing a summary of a patient's personal and demographic information) , the Face Sheet indicated the resident was admitted on [DATE] to the facility with diagnoses that included paranoid schizophrenia (mental illness characterized by a pattern of behavior where a person feels distrustful and suspicious 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 protect the health, welfare, rights and safety of 123 out of 123 residents by failing to screen potential employees for abuse, neglect (the failure to provide goods & services necessary to avoid physical harm, mental anguish, or mental illness), exploitation (the act of using someone or something unfairly for your own advantage), misappropriation of resident property (deliberate misplacement or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent) or mistreatment. This deficient practice placed residents at risk for abuse and neglect. Findings During a record review of the employee roster 2024, the employee roster indicated that since the last recertification in 2021, 1,005 new employees have been hired in the facility. During a record review of five randomly selected staff personnel files, two certified nurse assistants, two licensed vocational nurses, and one director of nursing, it was noted that no documented evidence of background screening was completed. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to ensure Resident 73's responsible party (RP) was informed in advance, of the risks and benefits of psychotropic medication (a drug that changes brain function and results in alterations in perception, mood, consciousness, or behavior) for one of five sample resident's. This failure resulted into violating the residents' right to make an informed decision regarding the use of psychotropic medications. Findings: During a record review of Resident 73's admission record (Face Sheet) , the Face Sheet indicated the resident was admitted on [DATE] to the facility with diagnoses that included anxiety, dementia(loss of cognitive functioning such as thinking, remembering, and reasoning which can affect and interfere with daily life and activities),psychotic and mood disturbance (refers to a collection of symptoms that affect the mind, where there has been some loss of contact with reality). During a record review of Resident 73's Minimum Data Set (MDS-…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to identify and assess one of five sampled residents (Resident 17) who had black discoloration and pain on his second toe of the right foot. This failure had the potential to cause delay of treatment and care to Resident 17. Findings: During a record review of Resident 17's admission record (Face Sheet document containing a summary of a patient's personal and demographic information), the admission record indicated the resident was admitted on [DATE] to the facility with diagnoses that included mesothelioma(type of cancer that occurs in the thin layer of tissue that covers the majority the internal organs), idiopathic neuropathy(nerves located outside of the brain and spinal cord are damaged and the cause is unknown), and cirrhosis of the liver ( liver is scarred and permanently damaged). During a record review of Resident 17's Minimum Data Set ([MDS] standardized screening tool) dated 2/16/2024, the MDS indicated the resident had moderately…

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 psychiatric consult on Resident who is receiving antipsychotic medications in the facility for one of 10 sampled Resident (Resident 108). This deficient practice has the potential for Resident 108 receiving continuous unnecessary medications without Psychiatric evaluation. Findings: During a record review of Resident 108's admission Record (Face sheet) indicated the resident was admitted to the facility on [DATE] with diagnosis including unspecified dementia (loss of memory, alcohol dependence(dependent on alcohol), bipolar disorder (mood swings). During a record review of Resident 108's Minimum Data Set {(MDS), a standardized assessment and care screening tool}, dated 3/4/24 indicated Resident 108 had severe cognitive (ability to make decisions, understand, learn) impairment, with daily decision making. The MDS assessment indicated the resident required supervision assistance or touching assistance for activities of daily living…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to monitor side effects of Xarelto(medicine used to prevent blood clots and could cause increased risk of bleeding) on one of three residents (Resident 315). This failure had the potential to place Resident 315 at risk for undetected and potentially life-threatening side effects of Xarelto. Findings: During a record review of Resident 315's Face Sheet( document containing a summary of a patient's personal and demographic information), the face sheet indicated the resident was admitted on [DATE] to the facility with diagnoses that included atherosclerotic heart disease of native coronary artery( buildup of fats, cholesterol and other substances in the blood vessels that supply the heart), and lobar pneumonia ( serious infection of one or more sections of the lungs). During a record review of Resident 315's History and Physical (H and P) dated 1/3/2024, the H and P indicated the resident did not have the capacity to understand and make decisions. During a…

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

Based on observation, interview and record review, the facility failed to observe infection control measures by not practicing hand hygiene in between task of medication preparation. This failure had the potential to contaminate medicines in the medication cart and cause spread of infection. Findings: During a medication pass observation on 5/9/2024 at 8:27 a.m. with Licensed Vocational Nurse (LVN 4), LVN 4 went into medication storage room and in the refrigerator of medication room and then proceeded to touch and move containers of medicines on the top shelf of the medication cart to look for acidophilus capsules ( medicine used to promote growth of good bacteria in the body) without practicing hand hygiene. During an interview on 5/9/2024, at 9:45 a.m. with LVN 4, LVN 4 confirmed she did not practice hand hygiene during medication pass and after coming from the medication storage room. LVN 4 stated she should have practiced hand washing to prevent spread of infection and possible contamination of other medicines on the cart. During an interview on 5/10/2024, at 8:45 a.m. with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect one of five sampled residents (Resident 1) right to be free from physical abuse by Certified Nursing Assistant (CNA) 3 when she slapped Resident 1 on the right side of the head and utter words in a threatening manner. This deficient practice resulted in Resident 1 was slapped by CNA 3 on the right side of the head and had the potential for Resident 1 to feel unsafe and unprotected. Findings: During a review of Resident 1 ' s Face Sheet, the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including Alzheimer ' s disease (a brain disorder that slowly destroys memory and thinking skills), dementia (brain disease causing memory problems), and hypertension (high blood pressure). During a review of Resident 1 ' s Minimum Data Set (MDS- comprehensive assessment and care screening tool) dated 1/26/2024, the MDS indicated Resident 1 had an impaired memory. During a phone interview on 3/28/2023 at 7:45 a.m. with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its abuse policy and procedure by failing to: 1. Protect one of five sampled residents (Resident 1) from physical abuse when Certified Nursing Assistant (CNA) 3 slapped Resident 1 on the left side of her head and utter words in a threatening manner. 2. Report to state agency (Department of Public Health) or the police department within two hours of the occurrence of incident and no later than 24 hours. These deficient practices resulted in CNA 3 slapped Resident 1 on the left side of her head and had the potential for Resident 1 to experience further abuse form CNA 3. Findings: During a review of Resident 1 ' s Face Sheet, the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including Alzheimer ' s disease (a brain disorder that slowly destroys memory and thinking skills), dementia (brain disease causing memory problems), and hypertension (high blood pressure). During a review of Resident 1 ' s Minimum…

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 witnessed physical abuse were reported to the state agency (Department of Public Health (DPH) or the police department within two hours of the occurrence of incident and no later than 24 hours for one of three sampled residents (Resident 1). This deficient practice had the potential to result in unidentified abuse in the facility and had the potential for Resident 1 to experience further abuse from Certified Nursing Assistant (CNA) 3 and protect other residents from abuse. Findings: During a review of Resident 1 ' s Face Sheet, the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including Alzheimer ' s disease (a brain disorder that slowly destroys memory and thinking skills), dementia (brain disease causing memory problems), and hypertension (high blood pressure). During a review of Resident 1 ' s Minimum Data Set (MDS- comprehensive assessment and care screening tool) dated 1/26/2024, 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 interview and record review, the facility failed to develop comprehensive care plan for one of five sampled residents (Resident 1) for abuse prevention. This deficient practice had the potential to negatively affect Resident 1 emotional and psychological wellbeing and affect the delivery of necessary care and services for Resident 1. Findings: During a review of Resident 1 ' s Face Sheet, the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including Alzheimer ' s disease (a brain disorder that slowly destroys memory and thinking skills), dementia (brain disease causing memory problems), and hypertension (high blood pressure). During a review of Resident 1 ' s Minimum Data Set (MDS- comprehensive assessment and care screening tool) dated 1/26/2024, the MDS indicated Resident 1 had an impaired memory. The MDS indicated Resident 1 had verbal behavior directed toward others such as threatening others, screaming at others , or cursing at others occurred one to three…

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 the temperature of resident rooms as outlined in the facility's policy and maintain a written log of the temperatures measured temperatures in the resident rooms. This deficient practice has the potential for all residents ' rooms to become too hot or too cold which could affect the safety and comfort of the residents at the facility. Findings: During a concurrent observation and interview on 10/12/2023, at 9:21 a.m., with the Director of Nursing (DON), in Station C of the facility, Station C including resident rooms and the adjacent hallways and nurse's station was observed to be on emergency power. It was observed that the facility did not have power to the heating, ventilation, and air conditioning (HVAC) system in Station C. The DON stated that Station C was on emergency power because the facility was working on updating an electrical panel and the facility was in the middle of the project. The DON stated that the project had been going for two weeks and that Section C had been without power…

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.