Lynwood Post Acute Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a care plan addressing the use of Apixaban (an oral anticoagulant [blood thinner] used to prevent stroke and blood clots) and risk for pressure ulcer (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) development for two of two sampled residents (Resident 4 and Resident 2).This deficient practice placed Residents 4 and 2 at risk for adverse drug reactions, unmonitored medication use, and the development or worsening of pressure ulcers.Findings: a. During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was admitted to the facility on [DATE]. Resident 4's diagnoses included type 2 diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing), muscle weakness, dysphagia (difficulty swallowing), multiple fractures (broken bone) of the ribs, hyperlipidemia (high cholesterol), rhabdomyolysis (is a serious,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 keep one of six sampled resident's (Resident 90) fingernails trimmed and clean. This deficient practice had the potential to result in a negative impact on Resident 90's quality of life and self-esteem, and had the potential for the development of infection.Findings: During a review of Resident 90's admission Record, the admission Record indicated Resident 90 was admitted to the facility on [DATE]. Resident 90's diagnoses included legal blindness (vision loss), muscle weakness (loss of muscle strength), and metabolic encephalopathy (an altered mental status). During a review of Resident 90's Minimum Data Set (MDS- a resident assessment tool), dated 1/28/2026, the MDS indicated Resident 90's cognitive skills for daily decision making (the ability to think and process information) was severely impaired. The MDS indicated Resident 90 was dependent (helper does all of the effort) on staff with activities of daily living (ADLs- routine…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 there were bilateral floor mats to the left and right side of the bed and ensure two intravenous (IV, into a vein) needles were properly disposed of for two of 12 sampled residents (Residents 13 and 2). These deficient practices placed Resident 13 at risk for injury, and the potential for unsafe handling of blood-contaminated sharps (devices with sharp points or edges designed to puncture or cut skin), with the potential for accidental needlestick injuries, and serious harm to Resident 2.Findings: a. During a review of Resident 13's admission Record, the admission Record indicated Resident 13 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 13's diagnoses included dementia (a progressive state of decline in mental abilities), syncope (passing out), and muscle wasting (weakening, shrinking, and loss of muscle). During a review of Resident 13's Minimum Data Set (MDS- a resident assessment tool),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide nutritional supplements, as ordered, to two of three sampled residents (Resident 41). This deficient practice placed Resident 41 at risk of not receiving her required amount of calories, protein, and other nutrients, increasing her risk for weight loss and other complications related to malnutrition.Findings: During a review of Resident 41's admission Record, the admission Record indicated Resident 41 was originally admitted to the facility on [DATE]. Resident 41's diagnoses included dysphagia (difficulty swallowing), moderate protein-calorie malnutrition, cachexia (a condition that causes significant weight loss and muscle loss), and adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity). During a review of Resident 41's Minimum Data Set (MDS, a resident assessment tool), dated 3/9/2026, the MDS indicated Resident 41…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Licensed Vocational Nurse (LVN) 2 demonstrated appropriate medication administration, documentation, and communication with the healthcare team, and failed to ensure licensed nursing staff used warm purified water when flushing (a medical procedure using a sterile sodium chloride [saline, salt and water] solution to clear, maintain, and prevent blockage in intravenous [IV- in a vein] catheters) a gastrostomy (G-tube- medical device inserted through the abdominal wall into the stomach to deliver nutrition, fluids, and medications directly, bypassing the mouth and esophagus) for two of six sampled residents (Resident 57 and Resident 2). This deficient practice did not respect Resident 57's right to be informed of and be involved in the care he was receiving. This deficient practice also had potential to negatively impact Resident 57's care from missed medications and inaccurate medical records and communication amongst his care team.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Hydrocodone-Acetaminophen (a medication used to treat pain) was administered according to the physician ordered parameters (specific, measurable, and objective clinical criteria set by a healthcare provider that dictate when a medication should be given, withheld, or adjusted) for one of six sampled residents (Resident 7). This deficient practice resulted in Resident 7 receiving Hydrocodone-Acetaminophen outside the physician-ordered parameter and had the potential for unnecessary opioid (narcotics, medications prescribed by doctors to treat persistent or severe pain) use, adverse medication effects, oversedation (when a patient receives an excessive amount of sedative agents, resulting in a deeper level of consciousness than intended), respiratory depression (when you breathe too slowly or too shallowly), constipation (occurs when your bowel movements become less frequent and stools become difficult to pass), and medication-related harm.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medication error rate was less than five percent (%) for one of five randomly selected residents. The outcome was ten (10) medication errors out of 29 opportunities for errors, resulting in an observed medication administration error rate of 34.48%.Findings: During a review of Resident 57's admission Record, the admission Record indicated Resident 57 was admitted to the facility on [DATE]. Resident 57's diagnoses included depression (mental mood disorder characterized by a persistent feeling of sadness, loss of interest in activities, and low energy), type 2 diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (HTN, high blood pressure), hyperlipidemia (an excess of fats in the blood that increases risk of heart attack and stroke), benign prostatic hyperplasia (BPH, a non-cancerous, age-related enlargement of the prostate gland), a broken left leg bone, and…

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

Based on observation, interview, and record review, the facility failed to store food properly in the kitchen when one bag of hamburger buns, two bags of wheat bread, ground Italian seasoning, plain salt, soy sauce, and powdered thickener were unlabeled and undated. This deficient practice had the potential to place the residents at risk for foodborne illness (is a sickness caused by eating that has harmful bacteria) or contamination (harmful germs get in food and unsafe to eat). Findings: During an observation on 4/20/2026 at 8:21 a.m. and at 11:53 a.m., in the facility kitchen, observed one bag of hamburger buns and two bags of wheat bread were observed open, unlabeled, and undated. Ground Italian seasoning, plain salt, soy sauce and powdered thickener were observed unlabeled and undated. During a concurrent observation and interview on 4/20/2026 at 12:10 p.m., with Dietary Aide (DA) 1, DA 1 stated the hamburger buns, two bags of wheat bread, ground Italian seasoning, plain salt, soy sauce, and powdered thickener were improperly stored. DA 1 stated that proper labeling and dating…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 two large trash containers located in the kitchen were maintained in a closed position. This deficient practice had the potential to contribute to environmental contamination, pest infestation, odors and unsanitary conditions that could negatively impact the health and safety of residents, staff, and visitors.Findings: During an observation on 4/20/2026 at 8:15 a.m. and at 12:02 p.m., in the facility kitchen, observed two large trash containers uncovered. The trash containers were filled to capacity with open fruit cans, empty bottles, soiled paper towels and wet meat bags. During a concurrent observation and interview on 4/20/2026 at 12:06 p.m. with Dietary Aide (DA 1), in the kitchen, two large trash containers were observed uncovered. DA 1 stated kitchen trash containers must remain closed when not in use at all times to prevent pests and to keep the facility safe. During an interview on 4/21/2026 at 10:22 a.m. with the Registered Dietician (RD), the RD stated open trash cans in the kitchen could…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Preadmission Screening and Resident Review (PASARR - a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) documentation was maintained and readily available in the resident's medical record for review for two of six sampled residents (Residents 1 and 8). This deficient practice resulted in incomplete medical records for Residents 1 and 8 and limited access to required PASRR documentation. Findings: a. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety (a feeling of worry, nervousness). During a review of Resident 1's Minimum Data Set ([MDS] - a resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the required personal protective equipment (PPE, clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) was worn while providing high-contact care to three of five sampled residents (Resident 6, Resident 94, and Resident 103) on enhanced barrier precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs]). This deficient practice increased the potential for spread of infection to Residents 6, 94, and 103.Findings: 1. During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was admitted to the facility on [DATE]. Resident 6's diagnoses included immunodeficiency (a state where the immune system's ability to fight infectious diseases and cancer is compromised or absent) due to drugs, presence of a gastrostomy (a surgical opening fitted with a device to allow feedings to 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the call light was easily accessible for one of six sampled residents (Resident 40), who had left-sided weakness. This deficient practice placed Resident 40 at risk for unmet care needs, delayed staff response, falls, injury, and inability to request assistance when needed. 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]. Resident 40's diagnoses included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) affecting the left side of the body and cortical blindness (a neurological vision impairment). During a review of Resident 40's Minimum Data Set (MDS- a resident assessment tool), dated 1/29/2026, the MDS indicated Resident 40's cognition (the ability to think and process information) was severely impaired. The MDS indicated Resident 40 was dependent (helper does all 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 maintain a safe environment when:1. The area around a circle floor drain cover in the hallway was cracked, uneven, and chipped with an irregular edge.2. There was no signage posted in a visible location, inside or outside of a resident room, to inform residents, staff, and visitors that oxygen was in use.These deficient practices placed the safety of all facility residents, staff, and visitors at risk due to trip hazards and potential fire hazard. Findings: a. During an observation on 4/20/2026 at 9:28 a.m., on 4/21/2026 at 1:18 p.m., and on 4/22/202 at 3:50 p.m., in the hallway by the kitchen door, a circle floor drain cover was observed cracked, uneven, and chipped with an irregular edge. During a concurrent observation and interview on 4/22/2026 at 3:56 p.m., with the Maintenance Supervisor (MS), in the hallway, observed the drain diameter measured 5.5 to 6 inches, with cracked flooring extending 0.5 to 1 inch outward from the edge.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 oxygen therapy (a medical treatment that provides extra oxygen to breathe, typically prescribed for individuals with conditions causing low blood oxygen levels) was administered as ordered by the physician for one of three sampled residents (Resident 1).This deficient practice placed Resident 1 at risk of sustaining complications of oxygen toxicity (e.g., serious tissue damage, respiratory failure, and central nervous system effects).Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's admitting diagnoses included chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 1/16/2026, the MDS indicated Resident 1 had severely impaired cognition (a significant decline in memory, thinking, and reasoning…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident-to-resident altercation for two of four sampled residents (Resident 2 and Resident 4) to the facility's Abuse Coordinator and the California Department of Public Health (CDPH) . This deficient practice created a delay in the investigation by the Abuse Coordinator and CDPH, and had the potential to result in further abuse.Findings:During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] and was readmitted [DATE]. Resident 2's diagnoses included anxiety disorder (mental health condition characterized by excessive, persistent, and uncontrollable worry or fear that interferes with daily life) and dementia (a progressive state of decline in mental abilities).During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 1/8/2026, the MDS indicated Resident 2 had no cognitive impairments (when a person has trouble with memory, thinking,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to investigate a resident-to-resident altercation that occurred on 1/31/2026, for two of four sampled residents (Resident 2 and Resident 4). This deficient practice had the potential to increase the risk for further abuse to occur.Findings:During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] and was readmitted [DATE]. Resident 2's diagnoses included anxiety disorder (mental health condition characterized by excessive, persistent, and uncontrollable worry or fear that interferes with daily life), and dementia (a progressive state of decline in mental abilities).During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 1/8/2026, the MDS indicated Resident 2 had no cognitive impairments (when a person has trouble with memory, thinking, learning, concentration, or decision-making). The MDS indicated Resident 2 could independently perform oral hygiene…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 it's policy and procedure (P&P) titled Resident-to-Resident Altercations, revised 9/2022, following a resident-to-resident altercation on 1/31/2026, for one of four sampled residents (Resident 4). This deficient practice created the potential for Resident 4 to not receive the care and interventions needed after the altercation on 1/31/2026.Findings:During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 4's diagnoses included chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), and congestive heart failure (CHF, a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling).During a review of Resident 4's Minimum Data Set (MDS), dated [DATE], the MDS indicated Resident 4 had no cognitive impairments (when a person has trouble with…

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

Based on observation, interview and record review the facility failed to provide one of three sampled residents (Resident 1) palatable food that was pleasant to taste, not overcooked, and appetizing.These failures placed Resident 1 at risk for missed meals and had the potential for weight loss.Findings:During a review of Resident 1's admission Record Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face sheet indicated Resident 1 was admitted to facility on 5/13/2026 with diagnoses including iron deficiency anemia(low iron in the blood), hypothyroidism (a common condition where the thyroid gland fails to produce enough essential hormones slowing down the body's metabolism), and hyperparathyroidism (an overactive parathyroid gland producing excess parathyroid hormone, causing high blood calcium).During a review of Resident 1 's History and Physical (H&P), dated 6/3/2025, the H&P indicated Resident 1 had the fluctuating capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS-a resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to exercise reasonable care for the protection of one of four sampled Resident's (Resident 1) property by failing to:1.Ensure Resident 1's Inventory List was completed at the time of discharge on [DATE].2. Ensure Resident 1's personal belongings (shirts and pants) were accounted for and provided to the Resident or the Resident's Family Member (FM) on discharge. These failures had the potential for Resident 1's personal belongings to be lost or stolen and could negatively affect Resident 1's psychosocial well-being. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing,) hypertension (HTN-high blood pressure) and chronic kidney disease (kidneys are damaged and can't filter waste from the blood).During a review of Resident 1'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 interview and record review, the facility failed to ensure a resident was free from misappropriation of personal property when Dietary Aide (DA) 1 agreed to withdraw cash and purchase cigarettes with the use of the resident's debit card for one of three sampled residents (Resident 1). This failure resulted in $8,000 worth of unauthorized cash withdrawals from Resident 1's bank account within a four-day span. This failure also violated Resident 1's right to be free from misappropriation and placed other residents at risk for similar exploitation. Cross-reference F609 and F610. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one entire side of the body) following a cerebral infarction (an interruption in blood flow to the brain), muscle weakness, and depression (persistent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their Policy and Procedure (P&P) titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, for one out of three sampled residents (Resident 1) by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 1 reported to the California Department of Health (CDPH), ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), and local authorities within 2 hours on 6/28/2025, after being made aware Dietary Aide (DA 1) was in possession of Resident 1's debit card from 6/25/2025 through 6/28/2025 and a total of $8,000 dollars was withdrawn from Resident 1's bank account without Resident 1's knowledge. 2. Ensure Social Services Designee (SSD) 1 reported to the CDPH, ombudsman, and local authorities on 6/30/2025, when she was first made aware of Resident 1's allegation of misappropriation (illegal use of someone else's money for purposes other than those intended by the rightful…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their Policy and Procedure (P&P) titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, for one out of three sampled residents (Resident 1) by failing to initiate and conduct a timely investigation into an allegation of misappropriation of resident property and missing funds when the following occurred: 1. Licensed Vocational Nurse (LVN) 1 was made aware on 6/28/2025, of an allegation that Dietary Aide (DA 1) was in possession of Resident 1's debit card from 6/25/2025 through 6/28/2025 and a total of $8,000 in unauthorized cash withdrawals from Resident 1's bank account occurred from 6/25/2025 through 6/28/2025. 2. Registered Nurse (RN) 1 was made on 6/28/2025 Resident 1's debit card and funds were missing. 3. Social Services Designee (SSD) 1 was made aware, on 6/30/2025, Resident 1's funds were missing. These failures resulted in a delay of protective measures for Resident 1. This failure also resulted in a delay…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a Registered Nurse (RN) was in the facility for at least eight consecutive hours on 12/7/2024, 12/8/2024, 12/15/2024, and 1/4/2025. This deficient practice had the potential to result in initial assessment to be delayed or missed and a potential to result in an overall decrease in the quality of care for the residents. Findings: During a review of the facility's Licensed Nurse Staffing, dated 12/1/20/24 through 12/31/2024, the Licensed Nurse Staffing indicated there was no RN scheduled during the 7 a.m. to 3 p.m. shift, 3 p.m. to 11 p.m. shift, nor the 11 p.m. to 7 a.m. shift on 12/7/2024, 12/8/2024, 12/15/2024, and 1/4/2025. During an interview on 1/15/2025 at 8:23 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated the RN who worked weekends was on sick leave and to fill the RN shift, one of the Minimum Data Set Nurses (MDSN), who were licensed RNs, would come in during the 7 a.m. to 3 p.m. shift. During an interview on 1/15/2025 at 1:42 p.m., with MDSN 1, MDSN 1 stated he usually worked Monday through…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 five sampled Residents (Resident 77 and 79)'s drug regiment was free of unnecessary medications by failing to: 1. Monitor the specific target behaviors for Resident 79's Zyprexa (olanzapine, an antipsychotic medication used to treat mental illness), Ativan (lorazepam, used to treat anxiety [excessive and persistent feelings of worry, fear, dread, and uneasiness that interfere with daily life), Desyrel (trazodone, antidepressant used to treat depression [a mood disorder that causes a persistent feeling of sadness and loss of interest] and anxiety disorders), Cymbalta (duloxetine, used to treat depression and anxiety), and Depakene (valproic acid, used to treat seizure (is a sudden rush of abnormal electrical activity in your brain) disorders, mental/mood conditions) and attempt nonpharmacological (without drugs) intervention prior to the initiation and during the use of psychotropic (any drug that affects behavior, mood,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and interview, the facility failed to ensure opened boxes of nebulizer solution (Ipratropium and albuterol combination, is used to treat chronic obstructive pulmonary disease (COPD, a condition that blocks airflow and make it hard to breathe) and other lung conditions, such as asthma [wheezing, difficulty breathing], chronic bronchitis [swelling of the air passages that lead to the lungs], and emphysema [damage to the air sacs in the lungs]) had an open date and was stored in accordance with manufacturer's specification for five of five residents (Residents 15, 35, 74, 19, and 12) inside of two of two Medication Carts (Medcart Station 1 and Medcart Station 2). The deficient practice of failing to label nebulizer solutions, Ipratropium and albuterol combination per the manufacturers' requirements increased the risk that residents with lung diseases could have received ineffective medication necessary to treat or prevent shortness of breath, breathing difficulties, chest pain, and coughing,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 practices in the kitchen when: 1. A container of apple sauce and jelly were not labeled with the product name, the open date, and the use-by date. 2. An opened container of chocolate crème pie was not labeled with the open date and the use-by date. These deficient practices had the potential to result in harmful bacteria growth that could lead to foodborne illness (transfer of bacteria from one object to another). Findings: During a concurrent observation and interview on 1/13/2025 at 8:12 a.m., with the Dietary Supervisor (DS), in the kitchen, Refrigerator 5 was observed to have two unlabeled containers of food items. The DS stated one container The DS stated one container contained apple sauce and the second container contained jelly. The DS stated the apple sauce and jelly were transferred from their original packaging and into the kitchen safe containers. The DS stated both containers were not labeled with the product name, the open date, nor the use-by date. The DS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care in a manner that maintained or enhanced a resident's dignity and respect for one out of eight sampled residents (Resident 9) when: 1. Certified Nursing Assistant (CNA) 3 failed to assist Resident 9 with grooming prior to a medical appointment. 2. Resident 9 was not fed prior to leaving the facility for his medical appointment. These deficient practices had the potential to cause a negative physiological outcome for Resident 9, and resulted in Resident 9 being hungry. Findings: During an observation on 1/13/2025 at 1:05 p.m., in Resident 9's room, Resident 9 was observed being picked up for a medical appointment. Resident 9's food tray was untouched and placed on the food cart. Resident 9 was not feed before he left to his medical appointment. During a review of Resident 9's admission Record, the admission record indicated Resident 9 was originally admitted to the facility on [DATE] and readmitted 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 observation, interview, and record review, the facility failed to obtain informed consent (voluntary agreement to accept treatment and/or procedure) for four of 16 sampled residents (Residents 77, 24, 81, and 85) by failing to: 1. Ensure Resident 77 gave informed consent for the continuation of olanzapine (a psychotropic medication [medication that affect the mind, emotions, and behavior]) after his readmission from the general acute care hospital (GACH) on 10/27/2024. 2. Ensure to obtain informed consent from the residents and/or responsible party (RP) before the use of physical restraints (a physical or mechanical device) for Resident 24, 81, and 85. This deficient practice resulted in Resident 77 being unaware of the risks, benefits, and indications of his use of olanzapine, therefore, unable to make an informed decision about his care, and violated Resident 22, 81, and 85's right to make an informed decision regarding the use of physical restraints. Findings: 1. During a review of Resident 77's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide reasonable accommodations for one of eight sampled residents (Resident 81) by failing to ensure the call light (a device that residents use to request assistance from staff) was within reach. This deficient practice had the potential to negatively impact the Resident 81's psychosocial well-being and/or result in delayed provision of care and services. Findings: During an observation on 1/13/2025 at 10:57 a.m., in Resident 81's room, Resident 81 was observed lying in bed. Resident 81's call light was on the floor on the left side of Resident 81's bed. During a review of Resident 81's admission record, the admission record indicated Resident 81 was admitted to the facility on [DATE] with diagnoses including collapsed (a break) vertebra (a bone in the spine that support weight and protect the spine), depression (loss of interest in activities), and chronic (constantly) pain. During a review of Resident 81's Minimum Data Set ([MDS]- 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 follow up and obtain a copy of an Advance Directive (a legal document indicating resident preference on end-of-life treatment decisions) for one of six sampled Residents (Resident 11). This deficient practice had the potential to result in the facility not honoring Resident 11's medical care directive in the event Resident 11 was to become incapacitated (unable to make informed decisions or care for themselves). Findings: During a review of Resident 11's admission Record (Face Sheet), the Face Sheet indicated Resident 11 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included heart failure (a chronic condition where the heart does not provide adequate blood flow to meet the body's needs), type two diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss 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 Minimum Data Set ([MDS] - a resident assessment tool) was accurately coded for one of eight sampled residents (Resident 40) to reflect Resident 40's oral and/or dental status. This deficient practice resulted in incorrect data transmitted to the Centers for Medicare and Medicaid Services (CMS) regarding Resident 40's dentures (oral appliances that replace missing teeth) and had the potential to negatively affect Resident 40's plan of care and delivery of necessary care and 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 dementia (a progressive state of decline in mental abilities), chronic obstructive pulmonary disease ([COPD]- a chronic lung disease causing difficulty in breathing), diabetes mellitus ([DM]- a disorder characterized by difficulty in blood sugar…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, and 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 resident's comfort and health) for three of 21 sampled residents (Residents 24, 40, and 42) by failing to: 1. Develop and implement a care plan for Resident 42's use of side rails (short rails on one or both sides of the bed that can be used to assist in bed mobility). 2. Initiate and implement a comprehensive care plan for Resident 40 who was using dentures (oral appliances that replace missing teeth). 3. Initiate and implement a comprehensive care plan for Resident 24 Restorative Nurse Assistant ([RNA]- a healthcare professional who help residents regain or maintain their mobility) program. These deficient practices had the potential to negatively affect Residents 24, 40, and 42's physical well-being and had 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 appropriate grooming and personal hygiene for one of eight sampled residents (Residents 18) by failing to keep Resident 18's fingernails clean and neat. This failure had the potential to result in a negative impact on Resident 18's quality of life and self-esteem and had the potential for the development of an infection. Findings: During a review of Resident 18's admission Record, the admission record indicated Resident 18 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including end stage renal disease ([ESRD] -irreversible kidney failure), muscle weakness (loss of muscle strength), and hypertension ([HTN]- high blood pressure). During a review of Resident 18's's Minimum Data Set ([MDS]- a resident assessment tool), dated 10/25/2024, the MDS indicated Resident 18's cognitive (the ability to think and process information) skills for daily decision making was intact. 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.

Based on observation, interview, and record review, the facility failed to obtain a physician's order for use of quarter side rails (short rails on one or both sides of the bed that can be used to assist in bed mobility) for one of two sampled residents (Resident 42), when Resident 42 used bilateral (left and right) quarter side rails for transfer assistance and bed mobility. This deficient practice had the potential to result in the unsafe use of side rails that could result in entrapment (becoming stuck between the bed and railing) and physical harm. Findings: During a review of Resident 42's admission Record (Face Sheet), the Face Sheet indicated Resident 42 was admitted to the facility with diagnoses that included fracture (a break or crack in the bone) of the right femur (bone of the thigh), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of the left knee, and acute embolism (a blood clot that enters the blood stream and blocks blood flow) and thrombosis (a blood clot that forms in a blood vessel, partially or completely blocking…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 licensed nursing staff practiced safe and effective medication administration practices for one out of eight sampled residents (Resident 90) by failing to: 1. Ensure Licensed Vocational Nurse 3 (LVN) administered medication to Resident 90 per the doctor's order. 2. Ensure LVN 3 did not falsely document she administered medication to Residents 90. 3. Ensure LVN 3 reordered medication for Resident 90. 4. Ensure LVN 3 did not administer another resident's medication to Resident 90. 5. Inform Resident 90 's doctor a medication was not administered as ordered. These deficient practices caused Resident 90 to have an interruption with medication therapy and pain control and exposed Resident 90 to a potential of a medication error and an adverse effect to their medications. Findings: During an observation on 1/15/2025 at 2:45 p.m., in the hallway, Resident 90 was observed asking staff to be wheeled to the front desk because her back hurt…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow and implement the pharmacist recommendation in the Medication Regimen Review (MRR) for one out of three sampled residents (Resident 9). This deficient practice had the potential to place Resident 9 at risk for complications due to bleeding. Findings: During a review of Resident 9's admission Record, the admission record indicated Resident 9 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing) and dysphagia (difficulty or discomfort in swallowing, as a symptom of disease). During a review of Resident 9's History and Physical (H&P) dated 6/13/2024, the H&P indicated Resident 9 had fluctuating capacity to understand and make decisions. During a review of Resident 9's Minimum Data Set (MDS), a mandated resident assessment tool), dated 11/22/2024, the MDS indicated that Resident 9's cognitive skills (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 interview and record review, the facility failed to ensure clinical records were complete and accurately documented for three out of five sampled residents (Resident 1, 143, and 144) by failing to ensure: 1. Licensed nurses documented the dates/times residents left and returned to the facility. 2. The Leave of Absence form (form licensed nurses fill out to clear resident to temporarily leave facility) was completed prior to residents leaving and returning to the facility. These deficient practices had the potential to create a miscommunication of the residents' location, whether the residents were cleared to leave the facility, and also created a safety concern. Findings: During a review of Resident 1's admission Record, the admission record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dependence on renal dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure infection control practices were followed for five of eight sampled residents (Resident 19, 8, 76, 90, and 15) by: 1. Failing to ensure Resident 19's nasal cannula (device used to deliver supplemental oxygen placed directly on the resident's nostrils) and humidifier (a medical device that adds water vapor to oxygen to help relieve dryness and irritation by oxygen therapy) were changed every seven days. 2. Failing to ensure a multiuse bottle of blood glucose (BG, a type of sugar) test strips used for multiple residents was not taken into and out of each of the following residents rooms (Residents 8, 76, 90, and 15) which increased the risk of cross-contamination, infection, and the spread of disease between residents whose blood was being tested during BG level checks (a test that measures the amount of glucose in the blood). These deficient practices had the potential to place Residents 19, 8, 76, 90, and 15 at risk for infection.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 intervention, as indicated in one of five sampled residents' (Resident 1) care plan titled, Resident has excessive tendencies of crawling and climbing out her bed, was impelmented. This deficient practice had the potential cause injury to Resident 1. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (a medical condition that occurs when blood flow to the brain is blocked, causing brain cells to die), alzheimer's disease (a brain disorder that destroys memory, thinking, and the ability to carry out daily tasks), and dementia (a group of thinking and social symptoms that interferes with daily functioning). During a review of Resident 1's History and Physical (H&P), dated 5/3/2024, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions. During a review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record review, the facility failed to report to the California Department of Public Health (CDPH), one of three residents (Resident 4), who was positive of Coronavirus Disease 2019 ([COVID-19] highly contagious viral infection). This failure resulted to the delay in investigation by the CDPH and had the potential for COVID-19 virus to spread infecting other residents, staffs and visitors in the facility. Findings: During a review of Resident 4 ' s admission Record, the admission record indicated Resident 4 was admitted to the facility on [DATE], with diagnosis that included epilepsy (disorder of the brain characterized by repeated seizures.), [NAME] ' s paralysis (seizure is followed by a brief period of temporary paralysis), and muscle weakness (loss of muscle strength) During a review of Resident 4 ' s history and physical (H&P) dated 8/7/2024, the H&P indicated Resident 4 had the mental capacity to understand and make medical decisions. During a review of Resident 4 ' 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 ensure kitchen staff adhered to menus approved by the Registered Dietician (RD), and their respective standardized recipes, while preparing meals for 86 out of 89 facility residents when the following occurred: 1. Resident 11 and Resident 40 received cheese and vegetable quesadillas that did not have vegetables. 2. The Dietary Supervisor (DS) did not make the Registered Dietitian (RD) and the residents of the facility aware of the menu substitution changes made on 1/23/2024 and 1/24/2024. The above failures had the potential for 86 out of 89 residents to not receive the expected calories, proteins, and other micronutrients (vitamins and minerals needed by the body in very small amounts) from the meals served by the facility. Findings: 1. During a review of Resident 11's admission Record, the record indicated the facility originally admitted Resident 11 on 10/24/2020 and re-admitted Resident 11 on 7/14/2023. Resident 11's admitting…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain informed consent prior to initiation and administration of psychotropics (medications that affect the mind, emotions, and behavior) to five of seven sampled residents (Residents 43, 52, 64, and 84, and 67). The above failure put Residents 43, 52, 64, 84, and 67 at risk for avoidable harm from unwanted adverse effects (a harmful and undesired effect resulting from a medication or intervention) related to psychotropic medication use. The above failure also removed the Residents' rights to make decisions about the care and treatments they received in the facility. Cross Reference: F-tag F561 Findings: 1. During a review of Resident 67's admission Record, the record indicated the facility originally admitted Resident 67 on 2/3/2023. Resident 67's admitting diagnoses included metabolic encephalopathy (when another health condition makes it hard for the brain to work), psychosis (a collection of symptoms that affect the mind, with some loss of contact…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and/or implement the care plans (document that assists nurses and other team care members organize aspects of resident care) for four of 46 sampled residents (Resident 23, Resident 11, Resident 51, and Resident 45) when facility staff failed to: 1. Develop a care plan for Resident 23 who had fungal dermatitis (a skin infection that causes red, irritated, or scaly rash) to her lower back. 2. Implement Resident 51's care plans for skin breakdown and pressure ulcers (PU, an injury that breaks down the skin and underlying tissue, caused when an area of skin is placed under prolonged pressure). 3. Implement Resident 11's care plans for skin breakdown and pressure ulcers. 4. Implement Resident 45's care plan for her impaired vision. These failures had the potential to negatively affect the delivery of necessary care and services for Residents 23, 11, and 45. Resident 23 was at risk for worsening fungal dermatitis; Resident 11 and Resident 51 were at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the residents' food was appealing, appetizing, and palatable (pleasant to taste) when the facility served pale-yellow, square-shaped egg bites for breakfast, when residents verbalized feelings of dissatisfaction of the facility's food due to the lack of palatability and appeal, and food served in disposable Styrofoam dinnerware which did not maintain temperature for nine out of nine sampled residents (Residents 29, 30, 68, 77, 82, 85, 90, 57 and 63). This deficient practice had the potential for the residents to experience poor meal intake and weight loss, and lack of dignity. Findings: During a review of Resident 29's admission Record, the admission Record indicated Resident 29 was originally admitted to the facility on [DATE]. Resident 29's diagnoses included but not limited to fracture of the humerus (broken arm bone), muscle wasting, and protein calorie malnutrition (nutritional status in which reduced availability of nutrients…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 appoint a responsible party and/or representative for one of 18 sampled residents (Resident 67), who did not have medical decision-making capacity. The above failure put Residents 67 at risk for avoidable harm from unwanted adverse effects (a harmful and undesired effect resulting from a medication or intervention) related to psychotropic medication use. The above failure also prevented Resident 67's from exercising his rights to make decisions about the care and treatments they received in the facility. Cross Reference: F-tag F552 Findings: During a review of Resident 67's admission Record, the record indicated the facility originally admitted Resident 67 on 2/3/2023. Resident 67's admitting diagnoses included metabolic encephalopathy (when another health condition makes it hard for the brain to work), psychosis (a collection of symptoms that affect the mind, with some loss of contact with reality), and major depressive disorder (a distinct type 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 During an observation, interview, and record review, the facility failed to ensure staff provided the necessary care and services for three of 18 sampled residents (Resident 36, 47, and 84) when: 1. Certified Nurse Assistant (CNA) 3 did not change Resident 36's diaper in a timely manner. 2. Resident 47 was not repositioned every 2 hours or as needed per the physician's order. 3. Resident 84 was not repositioned every 2 hours or as needed per the physician's order. These deficient practices had the potential to cause a negative impact on Resident's 36, 47, and 84's health and psychosocial well-being by not meeting resident's needs. Findings: 1. During a review of Resident 36's admission Record, the admission record indicated Resident 36 was admitted to the facility on [DATE] with diagnoses including Parkinson's (a progressive disorder that affects the parts of the body controlled by the nerves) and generalized muscle weakness (lack of muscle strength). During a review of Resident 36's History and Physical (H&P),…

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

Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 45) received glasses as recommended and prescribed by the optometrist (healthcare provider who specializes in caring for the eyes). This failure created the potential for Resident 45 to suffer from avoidable physical harm related to injury from inability to see, and psychosocial harm related to inability to watch television, which was her preferred activity in the facility. Cross Reference: F-tag 656 Findings: During a review of Resident 45's admission Record, the admission record indicated the facility originally admitted Resident 45 on 6/4/2020 and readmitted Resident 45 on 1/7/2022. Resident 45's admitting diagnoses included hemiplegia (paralysis [inability to move] one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following a stroke (damage to the brain from interruption of its blood supply), and aphasia (language disorder that affects a person's ability to communicate) following a stroke. 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 ensure that precautions were maintained to prevent the development or worsening of pressure ulcers (PU, an injury that breaks down the skin and underlying tissue, caused when an area of skin is placed under prolonged pressure) for two of two sampled residents (Resident 51 and Resident 11) when the following occurred: 1. Resident 51's weight was not accurately set on her low air loss mattress (LALM, a mattress designed to distribute body weight over a broad surface area to help prevent skin breakdown). 2. The Treatment Nurse (TN 1) was unaware of Resident 11's weight measurement to monitor accuracy of the LALM settings. The above failures had the potential to cause the avoidable development of skin breakdown for Resident 51 and the complications associated with impaired skin integrity. The above failures also increased the potential for Resident 11 to suffer an avoidable worsening in condition of her existing Stage IV PU (full-thickness…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents with a urinary catheter device (a flexible tube placed in the bladder used to collect urine by attaching to a drainage bag) received proper assessment and the urinary catheter and tubing were off the floor for two sampled residents (Resident 64 and Resident 84). These deficient practices had the potential for Resident 84 to have an undiagnosed urinary tract infection (UTI, bladder infection) and placed Resident 64's and Resident 84's urinary catheter drainage system at risk for possible exposure to infectious agents. Findings: 1. During a review of Resident 64's admission Record, the admission record indicated Resident 64 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities) and psychosis (a severe 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 connect the nasal cannula (device used to deliver supplemental oxygen or increased airflow through the nose) to the oxygen concentrator (a device that provides supplemental oxygen) when oxygen therapy was provided to one of three sample residents (Resident 60). This failure had the potential for Resident 60's oxygen saturation (amount of oxygen circulating in the blood, normal value 95 percent [%] to 100%) to decrease which could lead to shortness of breath and respiratory distress. Findings: During a review of Resident 60's admission Record (Face Sheet), the admission Record indicated Resident 60 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses included but not limited to chronic obstructive pulmonary disease (COPD, a lung disease characterized by long-term poor airflow), type 2 diabetes mellitus condition that results in too much sugar circulating in the blood), and schizophrenia…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 licensed staff failed to ensure the accurate and complete documentation of the administration of Lomotil (a controlled medication used to treat loose and watery stools, contains small quantities of narcotics) in the Medication Administration Record (MAR) and the Controlled Drug Record (CDR) to account for all eight doses (16 tablets) for one of three sampled residents (Resident 10). This failure had the potential for Resident 10 to overdose, the doses of Lomotil to become missing or unaccounted for, drug diversion (the act of health care providers stealing prescription medicines or controlled substances such as opioids for their own use), and/or the potential for a medication error to occur. Findings: During a review of Resident 10's admission Record, the admission Record indicated Resident 10 was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included but not limited to diabetes (poor blood sugar control) and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure their medication error rate was less than five (5) percent (5%) when three medication errors out of 38 total opportunities contributed to an overall medication error rate of 7.89%, affecting one of ten residents (Resident 85), based on the following: 1. Resident 85's heart rate was not assessed prior to the administration of hydrochlorothiazide (a medication used to treat high blood pressure and fluid retention) 12.g milligrams (mg, a unit of measurement) and losartan potassium (a medication used to treat high blood pressure) 25 mg. 2. Resident 85 was not instructed to rinse their mouth after the administration of one puff of Fluticasone-Salmeterol (a medication used to treat breathing problems). These failures had the potential for Resident 85 to experience medical complications such as bradycardia (a slow heart rate) which could lead to dizziness, chest pain, and confusion. These failures also had the potential for development 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 maintain medications in a proper storage room for two sampled Residents (Resident 1 and Resident 57) when: 1. Medicated ointment and another unidentified substance was stored in a resident restroom. 2. Medicated ointment and Vaseline was kept at Resident 1's and Resident 57's bedside. This deficient practice had a potential risk for a resident or residents ingesting the medications. Findings: 1. During a review of Resident 1's admission Record, the admission record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including chronic kidney disease (gradual loss of kidney function) and cardiomegaly (enlargement of the heart). During a review of Resident 1's History and Physical (H&P) dated 10/10/2023, 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 standardized resident 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.

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 6 and Resident 62) were provided the opportunity to make an informed decision prior to entering into a binding arbitration agreement (the submission of a dispute to a neutral party who hears the case and makes a decision) when the following occurred: 1. Facility staff did not inform Resident 6's responsible party about what a binding arbitration entailed, or that entrance into a binding arbitration agreement was optional. 2. Facility staff did not contact Resident 62's responsible party and power of attorney (POA, a legal document that allows someone else to act on your behalf), prior to Resident 62 signing a binding arbitration agreement. This failure caused Resident 6 and Resident 62, and/or their responsible parties, to unknowingly forfeit their right to resolve any disputes with the facility in court, with a judge and/or jury. Findings: 1. During a review of Resident 6's admission Record, the record…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 effective infection prevention measures for three of 11 sampled residents (Resident 23, 49, and 74) when the facility failed to: 1. Ensure Treatment Nurse (TN) 1 performed hand hygiene (a way of cleaning one's hands that substantially reduces the potential germs on the hands) throughout Resident 23's wound treatment. 2. Ensure Licensed Vocational Nurse (LVN) 2 donned (to put on) personal protective equipment (PPE, protective garments or equipment such as gowns, gloves, masks, eye wear that is designed to protect the wearer's body from infection) when providing care to Resident 49 and Resident 74 who were on Enhanced Standard Precautions (ESP, infection control intervention using gown and gloves during high contact resident care activities designed to reduce the transmission of multi-drug resistant organisms). These failures had the potential to result in the transmission of infectious microorganisms and increase the risk 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 three sampled residents (Resident 1 and Resident 3) were treated with respect and dignity by failing to knock and request permission before opening the curtain in the residents ' room. This deficient practice had the potential to violate the rights to privacy and negatively affect the psychosocial wellbeing of Resident and Resident 3. Findings: During a review of Resident 1 ' s admission Record (Face Sheet), the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] with diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing) of right side, end-stage renal disease ([ESRD], the final, permanent stage of chronic kidney disease, where kidney function has declined to the point that the kidneys can no longer function on their own), type 2…

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

Based on observation, interview and record review, the facility failed to follow their Infection Prevention and Control Policy and Procedures (P&P) by failing to ensure visitors and staff entering the facility completed screening for signs and symptoms (s/s) of Coronavirus Disease ([Covid-19] a highly contagious respiratory infection caused by a virus that could easily spread from person to person). This deficiency practice had the potential to result in the spread of Covid-19 amongst facility staff, residents and the community. Findings: During an observation on 11/21/2023 at 9:35 a.m., two visitors walked into the facility and were asked by Receptionist to sign in and check their temperature. The visitors proceeded to enter the facility without staff validating Covid-19 screening was done and that visitors had no s/s of Covid-19. During a review of the facility's Employee Daily Monitoring Log dated 11/2/2023 to 11/21/2023, the Log indicated sections for temperature, validation whether staff exhibited s/s of Covid-19 including fever, cough, shortness of breath, sore throat 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.

Based on observation, interview, and record review, the facility failed to ensure 26 of 28 coffee mugs were cleaned, washed, and sanitized before the coffee mugs were taken out of the kitchen and placed on the coffee cart A for use and to distribute coffee to the residents in the facility. This failure had the potential to cause cross contamination (transfer of bacteria or any organisms) and illness to the affected residents in the facility. Findings: During a concurrent observation and interview, on 10/17/2023, at 7:33 a.m., with Certified Nurse Assistant (CNA) 1, CNA 1 was wheeling the coffee cart A in Hallway A, and stated she was going to distribute coffee to the residents. The orange plastic coffee mugs (coffee mugs) were examined. CNA 1 stated 26 out of 28 coffee mugs were stained with brown residue and stated that the coffee mugs were not clean. CNA 1 stated if a resident had drunk from any of the 26 stained coffee mugs, then it could potentially cause the resident to get sick. During an interview on 10/17/2023, at 7:46 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 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 interview and record review, the facility failed to provide a room that was assessed and equipped to prevent the resident from eloping (to run away unnoticed) for one of four sampled residents (Resident 1) who was assessed as a high risk for elopement. This deficient practice resulted in Resident 1 eloping from the facility on 9/6/2023 and was missing for three (3) days. Findings: During a review of Resident 1's admission record, the admission record indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses including diabetes mellitus (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine) and schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions). During a review of Resident 1's History and Physical (H&P) dated 4/14/2023, 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 report resident to resident abuse within 2 hours for two out of three sampled residents (Resident 1 and Resident 2). This deficient practice had the potential to result in failure to protect residents from abuse. Findings: During a review of Resident 1's admission Record, dated 9/5/2023, the admission Record indicated Resident 1 was admitted on [DATE] with admission diagnosis that included vascular dementia (memory loss and cognitive difficulty with reasoning and judgment), diabetes mellitus (a disease that results in too much sugar in the blood), hemiplegia (muscle weakness or partial paralysis on one side of the body) and hemiparesis (weakness or the inability to move on one side of the body) following a cerebral infarction (brain tissue death). During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 8/17/2023, the MDS indicated Resident 1 was moderately cognitively impaired, and…

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

Based on interview and record review, the facility failed to develop and implement an effective infection prevention and control program (IPCP) based on the following: 1. The Infection Preventionist Nurse (IPN) was unable to provide proof of a system for monitoring and surveilling infectious diseases in the facility, other than infections where antibiotics had been prescribed to the resident. 2. The IPN was unable to furnish an infection prevention and control program or policy that clearly outlined who would be responsible for infection prevention and control tasks in the event the IPN was unavailable and failed to ensure the individual covering her responsibilities in her absence had the necessary training. 3. The IPN performed infection control and prevention duties while not in the facility. This failure created the potential for vulnerable facility residents to suffer from avoidable infections, such as COVID-19 (a disease caused by a virus named SARS-CoV-2, that can be very contagious and spreads quickly), while the facility was experiencing an active outbreak of 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.

Based on interview and record review, the facility failed to provide education to one of five sampled residents (Resident 9) on the potential side effects, risks, and benefits of receiving pneumococcal (pertaining to pneumonia [infection of the lungs]) and COVID-19 (highly infectious respiratory virus spread from person to person) vaccines. This deficient practice failed to allow Resident 9 to exercise her right to make an informed choice to accept or refuse three different vaccine doses. Findings: A review of Resident 9's electronic immunization records (EIR) indicated the facility administered three different immunizations to Resident 9. On 1/13/2022, the infection preventionist nurse (IPN) administered one dose of pneumococcal vaccine. On 11/30/2022, the IPN administered one dose of a COVID-19 vaccination. On 5/4/2023, Resident 9 received a second dose of the COVID-19 vaccine in the facility. Further review of Resident 9's EIR indicated the IPN confirmed that Resident 9 had consented to all three vaccinations but did not indicate that any education was provided to Resident 9 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.

Based on observation, interview, and record review, the facility staff failed to implement and/or maintain infection control measures when the following occurred: Staff did not perform hand hygiene prior to or after providing direct patient care to three of six sampled residents (Resident 1, Resident 5, and Resident 7). Staff did not don (put on) the required personal protective equipment (PPE, specialized clothing or equipment worn by an employee for protection against infectious materials) in rooms where residents were suspected of having COVID-19 (a disease caused by a virus named SARS-CoV-2 that can be very contagious and spreads quickly). Three licensed staff (Licensed Vocational Nurse 1 [LVN 1], LVN 2, and Registered Nurse Supervisor 1 [RNS 1]) wore N95 respirators (a filter mask that, if fitted properly, provides protection from biological particles such as bacteria and viruses) that they were not approved to use. These deficient practices had the potential to spread disease-causing pathogens from one resident to another, and from facility staff to residents, causing…

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