Pacific Care Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 75) was 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 physician order for the use of restraint was obtained before initiating a physical restraint in the form of a sock which covered the right arm and right hand with tape wrapping the fingers.2. Ensure an assessment and monitoring of the use of physical restraint for the right arm and hand were implemented and documented.This failure had the potential to place Resident 75 at risk for unnecessary prolonged use of restraints, and could lead to decline in physical functioning, impaired blood circulation, and skin injuries. Findings:During a concurrent observation and interview on 7/15/2025, at 10:35 a.m. in the room of Resident 75 with a family member (FM1), Resident 75's right arm and right hand were covered with a blue sock 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 observation, interview, and record review, Licensed Vocational Nurse (LVN) 4 failed to ensure Resident 8's Acidophilus ([generic name - lactobacillus] a probiotic supplement used to improve gut health) was completely dissolved before being administered via gastrostomy tube (g-tube - a surgically placed tube used to administer medications or food directly into the stomach). LVN 4 failed to safely administer medications via g-tube by failing to follow infection control practices throughout medications administration, for one of seven sampled residents observed during medication administration. This failure to administer g-tube medications for Resident 8 in accordance with professional standards of care and increased the risk for discomfort, clogging of g-tube, infection and contamination of medications. Findings:During a review of Resident 8's admission Record, dated 7/16/2025, the admission Record indicated, Resident 8 was originally admitted to the facility on [DATE] and readmitted on [DATE] 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 observation, interview, and record review, the facility failed to ensure that staff used a communication board (tool used for communicating with residents that speak another language) for one of four sampled residents (Resident 100) as written in her care plan. This deficient practice had a potential for staff to ineffectively communicate with Resident 100's care and had a potential to delay medicating Resident 100 when she complained of being in pain. Findings: During a review of Resident 100's admission Record , the admission Record indicated Resident 100 was originally admitted to the facility on [DATE] with diagnoses including cerebrovascular accident (CVA- stroke, loss of blood flow to part of the brain) and tracheostomy (surgically created opening in the neck that extends into the windpipe) with ventilator (a medical device to help support or replace breathing) dependence. During a review of Resident 100's History and Physical (H&P) dated 7/11/2025, the H&P indicated that Resident 100 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure one of one sample resident (Resident 53) received rehabilitation services or Restorative Nursing Aide ([RNA] nursing aide program that helps residents to maintain their function and joint mobility) services for the right-hand contracture. (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints).This failure had the potential to result in Resident 53 being at risk for further range of motion (ROM - the extent of movement of a joint) decline and contracture.Findings:During a review of Resident 53's admission Record, the admission Record indicated, Resident 53 was admitted to the facility on [DATE] with diagnoses including dysarthria (a speech disorder that occurs when muscles used for speaking become weak or are unable to coordinate properly), muscle weakness, hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one side of the body)…

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

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 66) was not left un-attendant in bed prior to transfer to a mechanical lift (Hoyer lift- (a device used to assist with transferring and moving individuals who have limited mobility) and bed should be locked.This failure had the potential for Resident 66 to fall out of bed and sustain injuries that require hospitalization. Findings:During a review of Resident 66's admission Record, the admission Record indicated Resident 66 was admitted to the facility on [DATE] with diagnoses including intracranial hemorrhage (brain bleed), cervical osteomyelitis (infection of the bone) , cervical discitis (an infection of the intervertebral discs in the neck), and cervical spondylolisthesis ( a condition where one of the vertebrae in your neck (cervical spine) slips forward, backward, or onto the vertebra below it).During a review of Resident 66's Care Plan, titled Risk for Fall, dated 4/27/2025, the Care Plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one of one sample resident (Resident 47) was provided with indwelling urinary catheter (a flexible tube inserted into the bladder to drain urine) care based on professional standards of practice and Resident 47's physician order. This failure had the potential for Resident 47 to develop a urinary tract infection (UTI- an infection in any part of the urinary system, the kidneys, bladder or urethra) and unable to assess Resident 47's intake and output.Findings:During a review of Resident 47's admission Record, the admission Record indicated, Resident 47 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including end stage renal disease (the final stage of chronic kidney disease (CKD) where the kidneys have significantly lost their ability to function adequately), hydronephrosis (a condition where one or both kidneys swell due to a backup of urine), retention of urine and diabetes mellitus (DM-a 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 interview and record review, the facility failed to ensure an annual performance evaluation (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics in performing that an individual needs to perform work roles or occupational functions successfully) was performed every year for Certified Nursing Assistant (CNA ) 2. This deficient practice had the potential for the facility not be able to assess the skills necessary for CNA 2 to provide nursing services to assure resident safety and to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Findings:During a concurrent interview and record review on 7/18/2025 at 12:01 PM with the Director of Staff Development (DSD), Certified Nursing Assistant (CNA) 2's employee file with a date of hire on 10/6/2010 was reviewed. CNA 2's employee file indicated the last performance evaluation was done on 10/15/2021. The DSD stated performance evaluations should be done yearly to talk about improvements and how to exceed expectations and to make sure 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 maintain a medication error rate of less than 5% (percent) during medication pass for two of seven sampled residents (Residents 40 and 80) by failing to:1. Administer Resident 40's artificial tears eye drops in the correct eye in accordance with physician orders.2. Administer Resident 80's metformin (a medication used to treat high blood glucose) within one hour of its scheduled time of administration as per facility's policy and procedure (P&P) titled, Medication Administration, dated 4/2025.These deficient practices resulted in a medication administration error rate of 5.71%, which exceeded the 5% threshold and had the potential to cause eye complications for Resident 40, hyperglycemia (high blood glucose) for Resident 80 and hospitalization for Residents 40 and 80.Findings:1. During a review of Resident 40's admission Record, dated 7/16/2025, the admission Record indicated Resident 40 was originally admitted to the facility on [DATE]…

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

Based on interview and record review, the facility's Quality Assessment and Assurance Committee (QAA) failed to ensure effective oversight and implementation of the facility's plan of correction (POC) of the deficient practices identified during the last recertification survey in 2024.This failure resulted in the facility to have repeat deficiencies in pharmacy services, quality of care and infection control.Findings:During a review of the facility's Statement of Deficiencies for the 2024 Recertification survey indicated the following repeat deficiencies in pharmacy services, quality of care and infection control.During a concurrent interview and record review on 7/18/2025 at 3:27 pm with the Administrator (ADM), the Quality Assurance Performance Improvement (QAPI- a data driven proactive approach to improvement used to ensure services are meeting quality standards) was reviewed. The ADM stated that QAPI was an ongoing program in the facility where the QAPI team analysis data and statistics to evaluate and identify concerns in the building to improve the quality of care for the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement and follow its protocol for antibiotic (medicine used to kill bacteria and treat infections) use on one of four sampled residents (Resident 55).This failure had the potential for Resident 55 to receive an inappropriate antibiotic which could lead to antibiotic resistance (occurs when bacteria evolve and develop the ability to withstand the effects of antibiotics, rendering these drugs ineffective).Findings:During a review of Resident 55's admission Record, the admission Record indicated the resident was admitted on [DATE] to the facility with diagnoses including methicillin resistant staphylococcus aureus infection (MRSA- caused by a type of staph bacteria that's become resistant to many of the antibiotics used for staph infections), obstructive and reflux uropathy(blockage in the urinary tract that prevents normal urine flow and backward flow of urine from the bladder towards the kidneys), chronic kidney disease( long term decline in kidney…

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 five of five sampled employees Certified Nursing Assistant (CNA) 2, CNA 5, , CNA 6, Licensed Vocational Nurse (LVN) 4, Director of Rehabilitation (DOR) and CNA 4 were offered the Covid-19 (an infectious disease caused by the SARS-CoV-2 virus) vaccine (a substance that is put into the body of a person to protect them from a disease) .This failure had the potential to place all residents and staff at risk for infection of Covid 19.Findings:During an interview on 7/18/2025 at 10:17 a.m., with the Infection Preventionist Nurse, (IPN), the IPN stated upon hire she makes sure employees have their Covid 19 immunization (the process of making a person resistant to a disease, typically through the administration of a vaccine) and any other immunizations. The IPN stated she offers employees the flu vaccine, Covid 19 vaccine, hepatitis vaccine and TDAP (a vaccine that protects against three diseases: tetanus, diphtheria, and pertussis). The IPN stated if the employee declines a vaccine the employee will sign the employee…

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 2) was free from verbal abuse when Licensed Vocational Nurse (LVN) 2 cursed at her. This deficient practice resulted in Resident 2 feeling unsafe when LVN 2 was working in the facility. This deficient practice had the potential to cause psychosocial (mental, emotional, and social) harm. Findings: During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with a diagnosis of anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). During a review of Resident 2's Minimum Data Set ([MDS] resident assessment tool) dated 2/5/2025, the MDS indicated Resident 2 was mildly cognitively (ability to think and reason) impaired. During a review of the facility's Investigation Report dated 2/26/2025, the Investigation Report indicated on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its abuse reporting and prevention policy titled, unusual Occurence Reported dated 8/2018 by failing to report an unusual occurrence of swelling of the left thigh due to unkown source, to the appropriate State Agencies, including the California Department of Public Health (CDPH) and the local Ombudsman, within 24 hours after the incident occurred for one of one sampled resident (Resident 1). As a result of the facility's failure to report Resident 1's left thigh swelling due to unknown source CDPH ' s investigation regarding the circumstances of Resident 1's injury was delayed. This deficient practice placed Resident 1 and other totaly dependent residents with severely impaired cognition (ability to think, understand, learn, and remember), to be at-risk for abuse, neglect, or mistreatment. During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses…

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 resident, who had a history of acute stroke ([CVA]- loss of blood flow to a part of the brain) and complained of having a slurred speech, a headache, and severe pain in left arm was timely transferred to a general acute care hospital (GACH) to prevent ischemic (a condition that occurs when blood flow to an organ, muscle group, or tissue is reduced resulting in a lack of oxygen) stroke for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure Licensed Vocational Nurse (LVN unknown) assessed Resident 1 when Certified Nursing Assistant (CNA) 1, reported on 1/9/2025 at 1 p.m. Resident 1 complained of having severe pain in left arm rated 9 out of 10 on a pain scale (pain screening tool using numerical value to assess the level of pain ranging from 0 to 3-mild pain, from 4 to 6- moderate pain, and from 7 to 9-severe pain, and 10- the worse pain possible) and verbalized of not feeling right. 2. Ensure the licensed nurses…

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 2 who has repeated threatening and abusive behavior was monitored for one of three sampled residents. This failure resulted in Resident 1 ' s being verbally abused and threatened by Resident 2. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of but not limited to schizophrenia (a mental illness that is characterized by disturbances in thought), diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), muscle weakness and chronic kidney diseases (progressive loss of kidney function). During a review of Resident 1's History and Physical (H&P) dated 9/20/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 9/22/2024, the MDS indicated Resident 1 needed maximal…

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 was turned every 2 hours to prevent the progression of a pressure injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence)as care planned for one of three sampled Residents (Resident 3) This failure had the potential to result in Resident 3's pressure injury to worsen and develop an avoidable pressure injury. Findings: During a review of Resident 3's admission Record (Face Sheet) , the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses of but not limited to stage four pressure ulcer (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) of the sacral (bottom of the spine) region, diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), dependence on a ventilator (a person unable to breathe on their own 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 observe infection control measures by failing to perform a Covid test ( screening test to rule out Covid-19 illness) on one of four sampled residents (Resident 2) who was showing signs and symptoms of a respiratory illness in a timely manner. This failure had the potential to put other residents and staff at risk for infection. Findings: During a review of Resident 2 's admission Record, the admission Record indicated the resident was admitted on [DATE] with diagnoses that included asthma( condition where a person's airways become inflamed, narrow, and swollen and produce extra mucus making harder to breathe), unspecified dementia( progressive state of decline in mental abilities), and history of Covid -19(viral and contagious respiratory illness). During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool)dated 10/19/2024, the MDS indicated the resident had severe cognitive skills( problems with a person's ability to think,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) will be offered to get out of bed in a wheelchair when resident ' s motorized wheelchair broke down. This failure put Resident 1 at risk for immobility and feelings of isolation and sadness. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated the resident was initially admitted on [DATE] and was readmitted on [DATE] to the facility with diagnoses that included hemiplegia and hemiparesis following cerebrovascular disease affecting left dominant side( loss of strength or paralysis on the left side of the body after a stroke), and osteoarthritis ( progressive disorder of the joints caused by gradual loss of cartilage). During a review of Resident 1 ' s History and Physical (H&P) dated 4/8/2024, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 1 ' s Minimum Data Set (MDS- a resident assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to provide rehabilitative services (services that help the resident keep, get back, or improve skills of functioning for daily living), as ordered by the physician, for one of one resident ' s (Resident 2). The facility failed to: a) Ensure Resident 2 received speech therapy (treatment that improve ability to talk and swallow) services three times a week, for the week of 3/5/2024. b) Ensure Resident 2 had documented evidence of Restorative Nursing Assistant (RNA) application of the bilateral (both) knee splints (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) from 3/15/2024 to 3/31/2024. These deficient practices placed Resident 2 at risk for not restoring or maintaining highest level of function. Findings: During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure (when the lungs and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to ensure one of two resident ' s (Resident 2) documentation was complete and accurate when Resident 2 ' s left lateral malleolus (the bone on the outside of the ankle joint) pressure injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) was described differently. Resident 2 ' s Wound consultant notes for 3/5/2024 indicated the pressure injury was a Stage III pressure injury (full-thickness loss of skin, dead and black tissue may be visible) and Resident 2 ' s Preliminary wound consultant notes for 3/5/2024 indicated it was an unstageable (when the stage is not clear because the base of the wound is covered by a layer of dead tissue) pressure injury. The deficient practices indicated an inaccurate depiction of Resident 2 ' s status. Findings: During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including acute respiratory…

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 verbal and physical altercation between two of six sampled residents (Resident 2 and Resident 6) was reported to the Administrator (ADM) and/or to the California Department of Public Health (CDPH), when Certified Nursing Assistant witnessed Resident 2 and Resident 6 throwing oatmeal at each other on 9/13/2024, and when Restorative Nursing Assistant 1 (RNA 1) witnessed a verbal altercation between Resident 2 and Resident 6 on 9/14/2024 and reported it to the ADM. This deficient practice resulted in the inability of CDPH to investigate the Resident to Resident altercations between Resident 2 and Resident 6 in a timely manner and had the potential for facts related to the allegations to be forgotten by staff and other witnesses. Findings: During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE], with a diagnosis of anxiety disorder (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 ensure a Hemodialysis Nurse 1 ([HDN 1] licensed nurses who specialize in the care of patients with kidney failure including treatment using hemodialysis [a lifesaving treatment and procedure for kidney failure that removes waste and extra fluids from the blood and regulates blood pressure]) and a Hemodialysis Technician 1 ([HDT 1] a healthcare professional who provides care to patients with kidney failure by performing and monitoring dialysis treatments) cleansed their hands using an alcohol-based hand rub (ABHR) or soap and water, and donned proper personal protective equipment ([PPE] clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments), a gown and gloves, before providing direct care to two of six sampled residents (Resident 7 and Resident 8). Resident 7 and Resident 8, who were undergoing hemodialysis treatment, and who were on enhanced barrier precaution ([EBP] an approach…

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 verbal altercation between two of six sampled residents (Resident 2 and Resident 2) that occurred on 9/14/2024, was investigated. This deficient practice resulted in the incident between Resident 2 and Resident 6 not being addressed and had the potential for continued conflict between the two residents. Findings: During a review of Resident 2 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE], with a diagnosis anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness). During a review of Resident 2 ' s Minimum Data Set ([MDS] a federally mandated resident assessment tool) dated 9/9/2024, the MDS indicated Resident 2 was able to make independent decisions that were reasonable and consistent. During a review of Resident 6 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 6 was admitted to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to re-admit one of three sampled residents (Resident 1), when Resident 1 was transferred to a General Acute Care Hospital (GACH) for evaluation of aggressive behavior, increased agitation, and refusal of care. The GACH cleared Resident 1 to return to the facility on 5/9/2024 but the facility refused to readmit her. This deficient practice resulted in Resident 1 remaining at the GACH (over five months after being transferred) and had a potential for Resident 1's continued displacement. Findings During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including a gastrostomy (a surgical procedure that creates an opening in the stomach wall through the skin of the abdomen to insert a small tube used for administration of nutrition and/or medication and schizoaffective disorder (a chronic mental illness that causes a person to experience dramatic changes in their…

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 safe and sanitary food storage and preparation practices for 89 of 89 residents when: 1. The inside compartment of the ice machine was observed with black residue. 2. A dented can of applesauce was not separated from the ready to use cans in the dry storage area. These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illnesses in all residents who received food and ice from the kitchen. Findings: a. During a concurrent observation and interview on 7/22/2024 at 8:40 a.m., with Certified Nursing Assistant (CNA) 2, in the dining room, a clean paper towel was used to swipe the ice storage bin ceiling and behind the plastic covering the ice dispensing area and brown and black residue was observed on the paper towel. CNA 2 stated a black and brown residue was on the paper towel after the inside of the ice machine was wiped. CNA 2 stated that kind of residue should not be…

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 Infection Preventionist (a person designated by the facility to be responsible for the infection prevention and control program) nurse (IPN) attended, participated, and gave findings on a regular basis to the Quality Assurance and Performance Improvement ([QAPI] a systematic, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes while involving all nursing home caregivers in practical and creative problem solving) committee during monthly meetings. This deficient practice prevented the QAPI Committee from receiving updated information regarding the facility's infection prevention program which had the potential to negatively impact residents' safety regarding infection control practices and outcomes in the facility. Findings: During a concurrent interview and record review on 7/23/2024 at 2:30 p.m. with the Administrator (ADM) and IPN 2, the QAPI committee meeting minutes and sign in sheets on 4/8/2024, 5/16/2024 and 6/20/2024 were reviewed. The QAPI committee…

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 practices by failing to: 1. Date Resident 29's peripheral intravenous catheter ([PIV] a small catheter placed into a vein to administer medication or fluids). 2. Change Resident 57's ventilator (a machine or device used medically to support or replace the breathing of a person who is ill, injured, or anesthetized) tubing per the facility policy. These deficient practices had the potential to result in phlebitis (infection/inflammation of the vein) for Resident 29 and pneumonia (infection of the lungs) for Resident 57. 3. Ensure Resident 26's nebulizer (a device used to administer medication in the form of a mist inhaled into the lungs) mask and tubbing was properly stored or changed as indicated in the facility's policy and procedure (P&P). This deficient practice had the potential to increase the risk for infection for Resident 26. 4. The incorrect isolation precaution (used to reduce the transmission 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 two of 12 sampled residents (Resident 15 and 77) were provided care and services to maintain good grooming and personal hygiene by failing to provide fingernail care for Residents 15 and 77 who were unable to carry out activities of daily living to maintain good personal hygiene. This deficient practice caused Resident 15's long fingernails to dig into the palm of his right hand and had the potential to cause an open wound which could lead to infection. This deficient practice also had the potential to negatively impact Residents 15's and 77's quality of care and self-esteem. Findings: a. During a telephone interview on 7/24/2024 at 9:48 a.m. with Resident 15's Family Member (FM 1), FM 1 stated when they visited Resident 15, Resident 15 frequently had fingernails that were uncut. FM 1 stated that the fingernails on Resident 15's right hand would pinch his skin and cause a cut to the middle of his palm. FM 1 stated the nurses 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 observation, interview and record review, the facility failed to ensure one of six sampled residents' (Resident 19) call light was within reach. This deficient practice had the potential to negatively impact Resident 19's quality of life and resident rights to have reasonable accommodations of needs. Findings: A review of Resident 19's, admission Record (Face Sheet), the admission Record indicated Resident 19 was admitted to the facility on [DATE] with diagnoses including cerebellar ataxia (poor muscle control that causes clumsy movements) and parkinsonism (slowed movements, stiffness, and tremors). A review of Resident 19's, Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated on 7/5/2024, the MDS indicated Resident 19 was cognitively intact (having the ability to think, learn, and remember clearly) and required substantial/maximal assistance (Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) from staff.…

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 staff failed to notify the psychiatrist when resident developed episodes of yelling for one of three sampled residents (Resident 19). This deficient practice had the potential to result in lack of necessary care, treatment, and delay medical interventions for Resident 19. Findings: During a review of Resident 19's admission Record ( Face Sheet), the Face Sheet indicated Resident 19 was admitted to the facility on 1218/2017 with diagnoses including schizophrenia ( a serios mental illness that effects how a person thinks, feels, and behaves), anxiety ( feeling of fear, restless, and tense), parkinsonism ( a brain condition that causes slowed movement, and tremors), and hypertension ( high blood pressure). During a review of Resident 19's Minimum Data Set ([MDS] a standardized assessment and care planning tool), dated 7/5/2024, the MDS indicated Resident 19 require maximum assistance (helper does more than half the effort) from staff for toileting hygiene, oral hygiene, and personal hygiene. During a review of Resident 19's History…

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 transmit to Centers for Medicare & Medicaid Services (CMS) the quarterly Minimum Data Set ([MDS] a resident screening and assessment tool) according to regulatory requirements for one of one resident (Resident 65) in a timely manner due to incomplete Section D (Mood) and E (Behavior). This deficient practice can potential negatively affect the delivery of necessary care and services for Resident 65. Findings: During a review of Residents 65 admission Record (Face Sheet), the admission Record indicated Resident 65 was initially admitted to the facility on [DATE] with diagnoses that include but not limited to quadriplegia (a form of paralysis that affects all four limbs plus the torso), muscle weakness (lack of muscle strength), osteoarthritis unspecified (degenerative joint disease in which the tissue in the joint break down over time), neuromuscular dysfunction of bladder (lack of bladder control due to brain or spinal cord injury).…

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 a person-centered care plan (document that helps nurses and other team care members organize aspects of resident care) with interventions (actions a nurse takes to implement a care plan, intend to improve the patient's comfort and health) for three of 12 sampled residents (Resident 1, 3, and 15) by failing to: 1. Develop a care plan for Resident 3 who required maximal assistance (helper does more than half of the effort) to dependent assistance with her activities of daily living ([ADLs], self-care activities such as bathing, toileting, and eating) and had unclear speech. 2. Develop a care plan for Resident 15 who received oxygen administration. 3. Develop a care plan for Resident 65 who required maximal assistance with his ADLs. These failures had the potential to negatively affect the delivery of necessary care and services for Resident 3, 15, and 65. Findings: a. During a review of Resident 3's admission Record (Face Sheet),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 15) remained on continuous oxygen at 3 liters per minute via nasal cannula (a device that gives additional oxygen through your nose) as ordered by the physician. This deficient practice had the potential to result in complications from lack of sufficient oxygen for Resident 15. Findings: During a review of Resident 15's admission Record, dated 5/31/2024, the admission record indicated Resident 15 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 15's diagnoses included cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), dysphagia (difficulty swallowing), gastroparesis (a disorder that slows or stops the movement of food from your stomach to the small intestine), hyperlipidemia (an excess of fats in the blood), and hypertension (high blood pressure). During a review of Resident 15's Minimum Data Set ([MDS] a comprehensive…

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 effectively manage resident's pain for one of one resident (Resident 27) by: 1. Failing to identify the resident's pain level after the administration of routine pain medication. 2. Failing to offer additional pain medication as ordered by the physician when Resident 27 continued to have pain 30 minutes after administering routine pain medications. These deficient practices caused Resident 27 to experience pain that interfered with activities of daily living and resulted in Resident 27 experiencing unrelieved pain. Findings: During a review of Resident 27's admission Record, dated 7/2/2024, the admission record indicated Resident 27 was initially admitted to the facility on [DATE] with the following diagnoses which included type 2 diabetes (condition that results in too much sugar circulating in the blood, muscle wasting (deterioration of muscle tissue), atrophy (a condition where a body part or tissue shrinks due to lack of use or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a dialysis (the process of removing waste products and excess fluid from the body) emergency kit ([e-kit], contains supplies such as tape, clamp, and gauze to use in case the resident experienced bleeding from their dialysis access site) was readily available at the bedside for one of three sampled residents (Resident 192). This deficient practice had the potential for Resident 192 to receive delayed intervention during accidental bleeding and could lead to hypotension and shock. Findings: During a review of Resident 192's admission Record (Face Sheet), indicated Resident 192 was admitted to the facility on [DATE] with diagnoses that include but not limited to urinary tract infection ([UTI], an infection in any part of the urinary system), end stage renal disease ([ESRD], a stage where the kidneys can no longer support the body's needs for waste removal and fluid balance), and atrial fibrillation (an irregular, often rapid heart…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to document the medication administration of controlled substances (drugs with accepted medical use but with an abuse potential) for one out of three residents (Resident 27). This deficient practice had the potential to harm Resident 27 by the likelihood of medication errors resulting from an inaccurate medical record, and also had the potential to cause Resident 27 harm by potentially not receiving the medication due to the loss of accountability which affects the control against drug loss (any loss of a controlled substance), diversion (transfer of a legally prescribed controlled substance from the individual for whom it was prescribed to another person for any illicit use), or theft. Findings: During a review of Resident 27's admission Record, the admission record indicated Resident 27 was admitted to the facility on [DATE]. Resident 27's admitting diagnosis included fibromyalgia (a disorder characterized by widespread musculoskeletal…

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 a medication error rate of five percent or less by failing to: 1. Check for gastrostomy ([g-tube] a surgical opening into the stomach for food and medication administration) tube placement (inserting air via a syringe into the g-tube and listening with a stethoscope to ensure the g-tube has not dislodged) for Resident 50 per policy and procedures (P&P). 2. Verify Resident 50 received the correct dose of Ferrous Sulfate (an iron supplement) 330 milligrams ([mg] a unit of weight measurement) per 7.5 milliliters ([ml] a unit of liquid measurement). 3. Ensure Resident 50's head of bed was greater than 30 degrees per P&P prior to administering medication via g-tube. 4. Disinfect an open vial of insulin (hormone medication used to aid the body in lowering the blood sugar) prior to preparing and administering to Resident 75. These deficient practices had the potential to result in an overdose of medication, infection, and aspiration…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to accurately label and discard expired medications and supplies, to ensure safe medication administration and diagnostic testing by failing to: 1. Ensure 69 packets of expired (2/9/2023) Banatrol Plus ([Banatrol] an antidiarrhea prebiotic supplement) and four (4) bottles of expired (11/2023) ultrasound gel was discarded from the medication storage room. 2. Label Artificial Tears (hydrating solution for dry eyes) eyedrops and Procure Miconazole Nitrate 2% (antifungal powder) with resident name and instructions. These deficient practices had the potential to administer expired medications with substandard therapeutic (producing a favorable result or effect) effects, administer medications not ordered, and to cross contaminate/ spread infection when medications were shared with other residents. Findings: During an observation on 7/25/2024 at 9:01 a.m., 4 bottles of expired (11/2023) ultrasound gel was discovered inside the bottom left cabinet…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the physician and/or the Nurse Practitioner (NP) when one of three sampled residents (Resident 1) aspirated (accidentally inhaling food or liquid through the vocal cords into the airway instead of swallowing through the food pipe) and vomited during feeding. This deficient practice resulted in a delay in treatment and a delay in transfer to a General Acute Care Hospital (GACH) for further evaluation and had the potential for Resident 1 to develop aspiration pneumonia (a type of pneumonia that occurs when a person breathes in food, liquid, or other substances into their lungs instead of swallowing them). Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including acute (sudden onset) respiratory failure (a serious condition that makes it difficult to breathe on your own), tracheostomy (a hole that surgeons make though the front of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed ensure the Respiratory Therapist ([RT] a medical professional who works with patients who have breathing problems or other lung conditions) obtained orders from the physician/nurse practitioner (NP) prior to changing ventilator settings (used ot control how much and how fast air is delivered to a patient's lungs) for one of three sampled residents (Resident 1) and Registered Nurse Supervisor 1 (RNS 1) and RNS 2 followed the recommendations of Resident 1's NP to transfer Resident 1 to a General Acute Care Hospital (GACH) when Resident 1's respiratory rate (RR) was abnormal and showed no signs of improvement. These deficient practices resulted Resident 1 receiving treatment that was not prescribed by Resident 1's physician or NP and a delay in transferring Resident 1 to a GACH for evaluation and treatment. This deficient practice had the potential for Resident 1's respiratory status to deteriorate resulting. Findings: During a review of Resident 1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility ' s Quality Assessment and Assurance ([QAA] a group which develops and implements appropriate plans of action to correct identified quality deficiencies) committee 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) committee failed to: 1. Have a policy and procedure (P&P) in place regarding the management and care of residents with the diagnoses of seizures, convulsions, and epilepsy, including how to identify those residents at risk and implement seizure precautions. 2. Identify, assess, and implement seizure precautions for 24 residents, in the facility with diagnoses of seizures, convulsions, epilepsy, and on anti-seizure medications These deficient practices placed 24 residents with diagnoses of seizure, convulsions, or epilepsy at risk for falls and injuries…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1), who resided at the facility and was transferred to a General Acute Care Hospital (GACH) for evaluation and treatment of an elevated heart rate, was readmitted to the facility after Resident 1 was treated and stabilized at the GACH. This deficient practice resulted in Resident 1 remaining at the GACH for five days after Resident 1 was deemed appropriate for discharge back to the facility but was denied readmission by the facility. Resident 1 was subsequently transferred to a different facility, placing the resident at risk for confusion, disorientation and psychosocial harm related to dislocation from a place that was considered Resident 1's home. Findings: During a review of Resident 1's admission Record (Face Sheet) the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included cerebral infarction ([stroke] disrupted blood flow to the brain due to problems…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) who experienced an assisted fall, sustained a right proximal fibula fracture (a break in the bone below the knee) and was assessed with pain, received pain medication to relieve his pain, per Resident 1's physician's order. This deficient practice resulted in Resident 1's unrelieved and increasing pain for approximately seven hours after falling and sustain a right proximal fibula fracture (12/18/2023). 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 to the facility on [DATE] with diagnoses including morbid obesity (more than 100 pounds over average body weight), and diabetes ([DM] a disease characterized by elevated levels of blood glucose [sugar]). During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 1/27/2024, the MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Family Member (FM 1) was notified when one of four sampled residents (Resident 1) fell on [DATE] at 2:15 a.m., 4:25 a.m., and 6:30 a.m. This deficient practice resulted in Resident 1 ' s FM 1 being unaware of Resident 1 ' s falls and had the potential to interfere with FM 1 ' s informed care decisions. Findings: A review of Resident 1 ' s admission Record (Face Sheet), indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including rheumatoid arthritis (a condition which causes pain, swelling and stiffness in joints), dementia (the impaired ability to remember, think or make decisions which interfere with doing everyday activities), and amnesia (a loss of memories, including facts, information, and experiences). A review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 12/5/2023, indicated Resident 1 ' s cognitive skills for daily decision-making were severely impaired. 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 report an allegation of physical abuse to the California Department of Health (CDPH), the State Long Term Care Ombudsman (an agency that provides support for residents of nursing homes, board and care homes and assisted living facilities) and the local Police Department within the regulated time frame of two hours for one of four sampled residents (Resident 1). This deficient practice resulted in a delay in the CDPH ' s investigation of the physical abuse allegation and had the potential for pertinent data to be lost and/or forgotten. Findings: A review of Resident 1 ' s admission Record (Face Sheet) indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of dementia (the impaired ability to remember, think or make decisions which interfere with doing everyday activities). A review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 12/5/2023, indicated Resident 1 ' s cognitive skills…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure three of seven sampled residents (Resident 1, Resident 5, and Resident 6) living condition were: a. free from direct/ indirect threatening remarks and acts of violence from a non-resident or visitor; and, b. free from noise or disruption from a visitor when their respective care and treatment is being provided. These deficient practices have resulted to Resident1, Resident 5 and Resident 6 to feel disrespected and unsafe in their environment and had the potential to negatively impact their physical and psychological well-being. Findings: A. During a review of Resident 1 ' s admission Record (Face sheet), the Face sheet indicated Resident 1 was admitted at the facility on 8/3/2023 with a diagnosis that included end stage renal disease (a medical condition in which a person ' s kidneys permanently stop functioning), diabetes mellitus a condition with inappropriate elevated blood sugar levels and hypertension (abnormally higher than normal blood…

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 primary physician 1(MD 1) recorded the cause of death in the progress notes; and completed and filed for a death certificate following one of one sampled resident's (Resident 1) death, as indicated in the facility ' s policy and procedure (P&P). This deficient practice delayed the necessary post mortem (after death) services for Resident 1. Findings: During a review of Resident 1 ' s face sheet (admission record), the face sheet indicated Resident 1 had an initial admission date of [DATE] and was readmitted on [DATE] with the diagnosis of intracranial hemorrhage (bleeding within the brain), sepsis (serious condition in which the body responds improperly to an infection), dysphagia (difficulty swallowing), aphasia (trouble speaking or understanding other people speaking) and traumatic brain injury (brain dysfunction caused by outside force usually a violent blow to the head). The face sheet indicated Resident 1's care provider was MD 1.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to identify, provide a comprehensive assessment and treatment for a change of condition (COC) for one of two (2) sampled residents (Resident 55 and 237) with hypoxia (not enough oxygen in the tissues to sustain bodily functions) and altered mental status(confusion/disorientation). These deficient practices resulted in Resident 55 and 237 receiving delayed provision of care and treatment, and transfer to a local acute care hospital. Findings: A. During an observation on 12/14/21 at 10:25 a.m., R55 was observed wearing a non- rebreather mask (a special medical device that helps provide oxygen in emergencies) on with the oxygen tank flow meter at 6 liters. Oxygen saturation monitor (machine used to measure oxygen in the blood) was on Resident 55 (R55) finger measuring at 90% (normal levels are greater than 92%) and the monitor was beeping continuously. R55 was observed with his eyes closed, hard to arouse (stay awake) and head of the bed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a spare tracheostomy tube kit was at the bedside for emergency use for one of three sampled residents (Resident 9). This failure had the potential to delay emergency treatment and further complicate resident 9's respiratory status. Findings: During a review of Resident 9's admission Record, the admission record indicated Resident 9 was admitted to the facility on [DATE], and was readmitted on [DATE] with diagnoses that included acute respiratory failure (condition in which the blood does not have enough oxygen or has too much carbon dioxide), tracheostomy (surgical opening created through the neck into the trachea (windpipe) to allow direct access to the breathing tube), cerebral infarction (stroke; damage to tissues in the brain), and hydrocephalus (a build-up of fluid deep within the brain). During a review of Resident 9's History and Physical (H&P), dated 7/15/21, the H&P indicated Resident 9 was in a chronic vegetative state…

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

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 75) who received hemodialysis (a medical procedure to remove fluid and waste products from the body) had the necessary supplies (clamp) to stop bleeding in the emergency kit at Resident 75's bedside. This deficient practice had the potential for resident 75 to receive delayed intervention during accidental bleeding. Findings: During a review of Resident 75's admission Record, the admission record indicated Resident 75 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure (condition in which the blood doesn't have enough oxygen or has too much carbon dioxide), tracheostomy (surgical opening created through the neck into the trachea (windpipe) to allow direct access to the breathing tube) cerebral infarction (stroke; damage to tissues in the brain), and end stage renal disease (permanent kidney function loss). During a review of Resident 75's History and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assess, obtain consent and orders for, and care plan restraint use for one of two (2) sampled residents (Resident 240). This deficient practice had the potential to result in Resident 240 sustaining injuries from being caught in between the rails or falling in attempts to climb over the rails, which would require additional care and treatment. Findings: During a review of Resident 240's Face Sheet, not dated, the document indicated the resident was admitted to the facility on [DATE] with diagnoses including cardiac arrest (abrupt loss of heart function, breathing, and consciousness), dependence on ventilator (a machine that delivers oxygen to the lungs to assist with breathing), tracheostomy (a surgically created opening through the neck into the trachea [windpipe] to help with breathing), end stage renal disease (ESRD - permanent kidney function loss), hypertension (high blood pressure), anemia (low number of red blood cells), dysphagia…

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 physicians initial face-to-face visit was made within 72 hours after admission for one of 18 sampled residents (Resident 28). This deficient practice had the potential to result in an undetected decline in medical, health or psychosocial condition and can lead to a delay in necessary care, treatment, and services. Findings: During a review of Resident 28's admission Record, the admission record indicated Resident 28 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included end stage renal disease (permanent kidney function loss), diabetes (chronic condition that affects how the body processes sugar), hypertension (condition in which the force of the blood against the artery walls is too high), and dysphagia (difficulty swallowing food or liquids). During a review of Resident 28's History and Physical (H&P), dated 6/14/21, the H&P indicated Resident 28 was a [AGE] year-old female admitted to the facility…

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 act upon the consultant pharmacist's recommendation in the Medication Regime Review (MRR), to clarify the indication for use of Haldol and Zyprexa (psychoactive medication-any medication capable of affecting the mind, emotions, and behavior) with the physician for one of four sampled residents (Resident 28) for unnecessary medications review. This deficient practice had the potential to cause Resident 28 to receive an unnecessary medication and can lead to adverse side effects. Findings: During a review of Resident 28's admission Record, the admission record indicated Resident 28 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included end stage renal disease (permanent kidney function loss), diabetes (chronic condition that affects how the body processes sugar), hypertension (condition in which the force of the blood against the artery walls is too high), and dysphagia (difficulty swallowing food or liquids).…

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 nursing staff performed proper hand hygiene and disinfection of wound care supplies for one of four (4) sampled residents (Resident 240) during wound care provision. These deficient practices had the potential to transmit infectious microorganisms and increase the risk of infection for Resident 240. Findings: During a review of Resident 240's Face Sheet, not dated, the document indicated the resident was admitted to the facility on [DATE] with diagnoses including cardiac arrest (abrupt loss of heart function, breathing, and consciousness), dependence on ventilator (a machine that delivers oxygen to the lungs to assist with breathing), tracheostomy (a surgically created opening through the neck into the trachea [windpipe] to help with breathing), end stage renal disease (ESRD - permanent kidney function loss), hypertension (high blood pressure), anemia (low number of red blood cells), dysphagia (difficulty swallowing food or…

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