Murrieta Health And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure an oxygen administration order was obtained for one of five sampled residents investigated for oxygen treatment (Resident 166).This failure could result in Resident 166 experiencing oxygen toxicity (lung damage caused by breathing excessive oxygen at high pressure) due to the administration of excessive or inappropriate supplemental oxygen, potentially leading to respiratory failure (when lungs cannot properly transfer oxygen into blood causing severe breathing difficulty).Findings:During a concurrent observation and interview on 3/2/26 at 10:37 AM with Resident 166, Resident 166 was in bed, alert, and verbally responsive. Resident 166 was receiving oxygen at a rate of four liters per minute through a nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen). Resident 166 stated that the previous oxygen administration rate was only two liters per minute, but it was likely that the…

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

Based on observation, interview, and record review, the facility failed to ensure accurate accountability of controlled substances (controlled substance [CS] - medications with high potential for abuse and addiction) when:The Controlled Drug Records ([CDR] - a medication count sheet, an inventory record used to document the receipt, use, and count of controlled substances) for one out of nine randomly selected residents (Resident 56) did not reconcile with the Medication Administration Record ([MAR] - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident).These failures resulted in inaccurate accountability of controlled substances, which had the potential for diversion (medication taken by someone other than for whom it is prescribed) or misuse of controlled substances and had the potential to compromise the residents' medication therapy and safety.Findings:During an inspection of Medication Cart 2A at Nursing Station 200 on 3/3/26 at 11:43 AM, a blister card for oxycodone-acetaminophen (generic for Percocet, a controlled…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facility record review, the facility failed to ensure the kitchen staff had the appropriate skill set to safely perform the daily operations of the Food and Nutrition Services Department.Dietary Aide (DA) 2 was unable to correctly explain the procedures to test the chemical concentration measured in parts per million (ppm - a unit of measurement) of the quaternary sanitizing solution (a chemical solution used to kill germs on surfaces) to sanitize food contact surfaces.This failure had the potential to expose 131 of 132 highly susceptible residents who received food from the kitchen to foodborne illnesses (any illness resulting from eating contaminated/spoiled foods) due to cross- contamination (the transfer of harmful substances or disease- causing microorganisms to food). During an observation and interview on 3/2/26 at 3:30 PM with DA 2, DA 2 was asked to demonstrate how to check the sanitizing solution. DA 2 stated she was not sure.A review of DA 2's personnel files indicated DA 2's date of hire was 3/18/25. During a concurrent interview 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 complete, accurate, and consistent documentation for two of 26 sampled residents' (Residents 59 and 60) medical records when:Resident 59's medical record did not accurately reflect the resident's PICC line (Peripherally Inserted Central Catheter - a thin flexible tube inserted to a large vein in the upper arm used to deliver medications for long term treatments) dressing change. 2. Resident 60's activity records were not accurately and consistently completed. These failures had the potential for these two residents to receive inconsistent care coordination and unmet care needs. Findings:1. During an initial tour observation on 3/2/26 at 9:38 AM, in the resident's room, Resident 59 was awake, verbally responsive, and comfortably lying on his bed. Resident 59 had a PICC line dressing on his right upper arm dated 2/16/26. During a concurrent observation and interview on 3/2/26 at 11:28 AM with Registered Nurse (RN) 2, RN 2 read the…

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

Based on observation, interview, and record review, the facility failed to keep the resident call light system (a device that residents can press to ask staff for help) in good working order for two of 26 sampled residents (Residents 13 and 171). This failure had the potential to delay staff response to resident needs and compromise resident safety.Findings:During a concurrent observation and interview on 3/2/26 at 8:59 AM with Certified Nursing Assistant (CNA) 1, CNA 1 tested the call light system in Resident 13 and Resident 171's rooms. Both call light systems did not show a light or were audible at the nursing station. CNA 1 verified that the call light system for both residents was not working.During a concurrent follow-up observation and interview on 3/2/26 at 11:59 AM with CNA 1, CNA 1 tested the call light system in Resident 13 and Resident 171's rooms again. Both call light systems still did not show a light or were audible at the nursing station. CNA 1 verified that the call light system for both residents were still not working.During an interview on 3/2/26 at 12:12 PM…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care and treatment was provided, for one of four residents reviewed (Resident A), when Resident A had high blood pressure.This failure had potential for a delay in the care and treatment to address Resident A's high blood pressure and could affect the resident's overall health condition.Findings:On January 27, 2026, at 9:15 a.m., an unannounced visit was conducted to investigate a quality-of-care issue.On January 27, 2026, Resident A's record was reviewed. Resident A's admission Record, indicated the resident was admitted to the facility on [DATE], with diagnoses which included hypertension (high blood pressure).A review of Resident A's Order Summary Report, included a physician's order, dated November 18, 2024, which indicated, .Terazosin HCL (medicate to treat high blood pressure) Oral Capsule 1 (one) MG (milligram - unit of measurement).Give 1 (one) capsule by mouth at bedtime for systolic (the first (top/upper) number) of > (more than) 140.A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of six sampled residents (Resident 1) was discharged to a facility that would be able to provide the care required by the resident. Resident 1 was discharged to an assisted living facility (ALF- a residential community providing housing, meals, and personalized support for older adults or people with disabilities who need help with daily activities [ADLs- activity of daily living] but not round the clock skilled nursing [high level medical care requiring the expertise of licensed professionals like registered nurses, licensed vocational nurses, and therapist]), which was unaware of the presence of the unstageable pressure injury ( a full thickness skin and tissue loss where the actual depth of the wound is completely obscured by slough [soft, yellowish, stringy, dead tissue] or eschar) on the right heel. This failure resulted in Resident 1 being transferred to a general acute care hospital (GACH), on the day Resident 1 was discharged from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to assess the bruise on the right arm for one of six sampled residents (Resident 1), when it was initially observed by a Certified Nursing Assistant (CNA) on November 17, 2025.This failure resulted in delayed provision of interventions which placed the resident at risk for complications.Findings:On December 2, 2025, at 9:30 a.m., an unannounced visit to the facility was conducted to investigate allegations of abuse and quality care concerns. A review of Resident 1's admission Record, indicated the resident was admitted to the facility on [DATE], with diagnoses which included heart failure, hypertension, and type 2 diabetes mellitus. On December 2, 2025, at 3:30 p.m., during a phone interview. CNA 1 stated she worked evening shift (3 p.m.-11 p.m.) on November 17, 2025, and cared for Resident 1. She stated she observed the resident with a bruise on the right forearm and she notified the licensed nurse. CNA 1 stated she was not sure what happened after she…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, for two of four residents (Residents A and B), were free from abuse when: 1. For Resident A, Certified Nursing Assistant (CNA) 1 refuses to take care of the resident and stated I am not your slave, and 2. For Resident B, CNA 1 provided care to the resident in a rough manner. These failures had the potential for Residents A and B to experience physical and emotional distress from the abuse from CNA 1. Findings: On June 11, 2025, at 9:50 a.m., an unannounced visit was made to the facility, for the investigation of an allegation of abuse. On June 11, 2025, at 10:00 a.m., an interview was conducted with the Administrator (Admin). The Admin stated on the morning of May 26, 2025, he had received a call from Licensed Vocational Nurse (LVN) 1, regarding CNA 1 was being rough with Resident B, and an allegation of abuse was reported. The Admin stated CNA 1 was interviewed and said there was a change in assignments when he first came in, and when he went…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an allegation of abuse by a Certified Nursing Assistant (CNA) was reported to the California Department of Public Health (CDPH - a State Agency [SA]) immediately or within two hours according to the facility policy and procedure, for one of four residents (Resident B). This failure had the potential to result in the delay in the investigation of the allegation of abuse and could further expose the vulnerable residents from further abuse. Findings: On June 11, 2025, at 9:50 a.m., an unannounced visit was conducted at the facility to investigate an allegation of abuse. On June 11, 2025, at 10 a.m., an interview was conducted with the Administrator (Admin). The Admin stated on the morning of May 26, 2025, he had received a call from Licensed Vocational Nurse (LVN) 1, regarding CNA 1 was being rough while providing care to Resident B. The Admin stated LVN 1 asked him how to fill out the abuse paperwork, he went over the procedure with 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 observation, interview, and record review, the facility failed to ensure call lights were answered timely, for three of five sampled residents, (Residents 1, 3, and 5). This failure had the potential to negatively affect Residents 1, 3, and 5's psychosocial well-being, and could affect the residents' overall health condition. Findings: On March 27, 2025, at 5:32 a.m., an unannounced visit was conducted at the facility to investigate a complaint regarding quality of care. 1. On March 27, 2025, at 6:50 a.m., Resident 3 was observed sitting at the side of the bed in a hospital gown and was watching television. In a concurrent interview with Resident 3, she stated the call lights were usually answered within 20 to 30 minutes from 6 p.m. to early morning. Resident 3 stated when the call lights were not answered at all, she would wheel herself out to the nursing station. On March 27, 2025, Resident 3's record was reviewed. Resident 3's admission Record, indicated Resident 3 was admitted to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure an assessment for safe self-administration of medication was conducted, for three of 28 residents (Resident 382, 388, and 389) when: 1. One opened box of Allergy Calm (brand of tablet used to treat allergies) tablet medication was found on the over bed table of Resident 382; 2. One opened plastic bottle of 15 ml (milliliters - unit of measurement) Afrin (brand of nasal spray used to treat congestion) nasal spray was found on the over bed table of Resident 388; and 3. One opened 77 g (grams- unit of measurement) tube of Alevex (brand of lotion use for pain) lotion was found on the over bed table of Resident 389. These failures had the potential for Residents 382, 388, and 389 to receive multiple doses of medication without proper monitoring, which could lead to harmful effects. Findings: 1. On December 9, 2024, at 10:44 a.m., during a concurrent observation and interview with Resident 382 in her room, one box of AllergyCalm tablet…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 respiratory tubings were changed according to the facility's policy and procedure, when: 1. For Resident 17, the nebulizer tubing (tubing that turns liquid medication into a mist that can be inhaled) was dated June 23, 2024; 2. For Resident 19, the nebulizer tubing, oxygen tubing (nasal cannula [N/C] - a tube used to deliver oxygen through the nose), and the tubing from the humidifier bottle to the oxygen concentrator (plastic bottle that infuses the normal flow of oxygen with water droplets) were all dated November 21, 2024; and 3. For Resident 80 the oxygen tubing and humidifier bottle (moistens the air) were dated November 24, 2024. This failure had the potential to result in deterioration of the respiratory tubing and humidifier bottle which would allow infectious organisms to grow causing an infection to Residents 17, 19, and 80. Findings: 1. On December 9, 2024, at 10:40 a.m., Resident 17's nebulizer tubing was observed with a…

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

Based on observation, interview, and record review, the facility failed to ensure provision of pharmacy services met the needs of the residents when: 1. Residents 88 and 101's discontinued and expired medication were identified stored inside a medication cart along with active/unexpired medications. This had the potential for residents to receive the wrong medication; and 2. Residents 90, 76, and 55's medical record had missing documentation for the administration of controlled substance (CS - those with high potential for abuse and addiction) medications. The CS medications were signed out on the Antibiotic or Controlled Drug Record Medication (count sheet, an inventory sheet that keeps record of the usage of controlled medications), but not documented on the Medication Administration Records (MAR) to indicate they were administered to the residents. This had the potential for misuse or abuse of the CS medications. Findings: 1. On December 9, 2024 at 10:44 a.m., during an inspection of Medication Cart 3 in Nursing Station 3A with Licensed Vocational Nurse (LVN) 6 the following were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure, for two of five sampled residents (Residents 34 and 5) were free from unnecessary psychotropic (drugs that affects brain activities associated with mental processes and behavior) medications, including quetiapine (brand name Seroquel, an antipsychotic medication for bipolar disorder, depression, and schizophrenia) when: 1. Resident 34 was administered quetiapine without an appropriate indication and/or clinical justification, without an annual GDR (gradual dose reduction) attempt in 2024, and no resident-centered non-pharmacological (any treatment or method used to improve health that doesn't involve taking medication) behavioral interventions were implemented prior to initiation and during use of quetiapine; and 2. Resident 5 was administered quetiapine without resident-centered non-pharmacological behavioral interventions implemented prior to initiation and during the first two months of quetiapine use. These failures resulted in unnecessary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medication were properly stored and labeled when: 1. One (1) expired medication was stored in the medication cart together with unexpired medications; 2. Opened medications were stored without an open date; 3. IV (intravenous - into the vein) Cart 3 contained several expired IV supplies; and 3. The treatment cart contained multiple expired wound care supplies. These failures had a potential for residents to receive medications or medical supplies with unsafe and reduced effectiveness from being used past their discard date; medication errors due to medications not being labeled or removed from active stock; and inadequately monitored medications, which could lead to unsafe and ineffective medications for the residents. Findings: 1. On December 9, 2024 at 10:44 a.m., an inspection of Medication Cart 3 in Nursing Station 3A was conducted with Licensed Vocational Nurse (LVN) 6, one medication blister card for Resident 88 containing 26…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, sanitary food preparation and storage practices were followed in the kitchen when: 1. Brown-black substance was observed in several areas where the walls and ceiling seams meet in the walk-in refrigerator; 2. Ice formed on the inside doors and seals of the six-door reach-in freezer; 3. Several open packages of food items were observed in the reach-in freezer; and 4. Air vents on the ceiling had brown dust coating. These failures had the potential to cause food-borne illnesses in a highly susceptible resident population. Findings: On December 9, 2024, at 9:10 a.m., an observation of the facility kitchen and concurrent interview with the Registered Dietician (RD) and Dietary Assistant (DA) was conducted. On December 9, 2024, at 9:24 a.m., an observation of the walk-in refrigerator was conducted with the RD. In the back two corners and the front right corner of the walk-in refrigerator, brown-black substance were observed along the seams where metal wall meets the metal ceiling. In a concurrent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 implemented when: 1a. The nursing staff failed to properly clean and disinfect shared blood pressure (BP- pressure of blood in blood vessels) cuff according to the disposable bleach wipe manufacturer's specified contact time (the time the resident equipment was to be in contact with the bleach disposable wipes to kill micro-organisms). In addition, the facility failed to properly clean and disinfect the shared stethoscope after use according to facility's policy, for Residents 282, 283 and 100; 1b. The nursing staff failed to properly clean and disinfect the resident's prefilled insulin (medication for diabetes) pen before use according to manufacturer's specifications. In addition, the facility failed to disinfect the shared glucometer (blood glucose meter to measure and display the amount of sugar [glucose] in your blood) after use according to the disposable bleach wipe manufacturer's specified…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 treat resident with dignity and respect, for one 130 residents (Resident 385), when the resident's urinary bag was not covered with a dignity bag (used to cover a urine collection bag). This failure had the potential to affect Resident 385's psychosocial well being. Findings: On December 9, 2024, at 2:30 p.m., Resident 385's urinary bag was observed hanging at the side of the bed and was not covered with a dignity bag. In a concurrent interview with Resident 385, she stated the urinary bag was not covered when she walked outside of her room and the resident stated she felt embarrassed when people see her urinary bag. On December 9, 2024, at 3:26 p.m., Resident 385 was observed with Licensed Vocational Nurse (LVN) 2. In a concurrent interview, LVN 2 stated the staff did not cover the urinary bag with a dignity bag and was exposed to everyone. LVN 2 further stated, It should have been covered, I would feel embarrassed if that bag was mine…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 copy of the Advance Directive (AD - a written instruction, such as a living will, relating to the provision of treatment and services when the individual becomes unable to decide) was available in the medical record, for one of one residents reviewed for Advance Directives (Resident 68). This failure had the potential to result in Resident 68's wishes related to the provision of medical treatment and services to not be followed if Resident 68 became unable to make decisions for himself. Findings: On December 10, 2024, Resident 68's record was reviewed. Resident 68 was admitted to the facility on [DATE], with diagnoses which included end stage renal disease (permanent stage of kidney disease). A review of Resident 68's History and Physical dated December 11, 2024, indicated Resident 68 had the capacity to understand and make decisions. A review Resident 68's Social Service Review, dated November 2, 2024, indicated Resident 68 had an AD and a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a comfortable homelike environment, for one of 28 residents reviewed (Resident 384), when multiple damaged window blinds were observed. This failure had the potential to disrupt the residents' daily living needs and environment. Findings: On December 9, 2024, at 9:45 a.m., during a concurrent observation and interview with Resident 38 in her room, multiple damaged blinds were observed. In a concurrent interview with Resident 384, she stated it was too bright when light would come on the window when she wakes up in the morning, and she could not get back to sleep. On December 10, 2024, at 9:20 a.m., Resident 384's window was observed to have about two layers of horizontal blinds broken. On December 10, 2024, at 9:27 a.m., a picture of Resident 384's broken blinds were shown to the Assistant Director of Nursing (ADON). The ADON stated Resident 384 had broken blinds and would not feel home-like environment for the residents. The ADON…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the facility's policy and procedure on antibiotic stewardship (a set of coordinated efforts aimed at promoting the appropriate use of antibiotics to optimize patient outcomes while minimizing the risk of antibiotic resistance and adverse effects), for one of five sampled residents reviewed (Resident 390) when there was a delay in obtaining the urinalysis specimen and was not evaluated for antibiotic time out (a healthcare practice where a review of antibiotic therapy occurs within a predetermined time frame after the initial prescription) within 72 hours. These deficient practices had the potential to result in the development of antibiotic-resistant organisms (organisms not affected by antibiotics). Findings: On December 11, 2024, Resident 390's record was reviewed. Resident 390 was admitted to the facility on [DATE], with diagnoses which included dysuria (difficulty in urination). A review of Resident 390's Progress Notes, dated December 3,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the pneumococcal vaccine (vaccines against the bacterium Streptococcus pneumoniae [bacteria that can cause pneumonia]) was offered, for one of five residents reviewed for immunizations (Resident 31) . This failure had the potential for Resident 31 not fully be protected against pneumonia (infection of lungs). Findings: On December 11, 2024, Resident 31's medical records were reviewed. Resident 31 was admitted to the facility on [DATE], with diagnoses which included muscle weakness and Alzheimer's disease with late onset (memory loss). On December 11, 2024, at 10:30 a.m., during a concurrent interview and record review of Resident 31's immunization record, with the Infection Preventionist (IP), the IP stated Resident 31 received one dose of pneumococcal (PCV13- prevnar13) vaccine on June 15, 2015. The IP stated residents who received one dose of Pneumococcal (PCV13) should be offered a dose of pneumococcal (PCV20) after one year. The IP stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately document in the Electronic Medication Administration Record (EMAR) scheduled time of medication administration, for one of three residents (Resident 1). This deficient practice can have the potential for inappropriate communication between the staff and an inaccurate picture of resident's care. Findings: On August 7, 2024, at 8:55 a.m., an unannounced visit was conducted at the facility to investigate a complaint for quality of care, accidents, physical environment, and a nursing services issue. On August 7, 2024, Resident 1's facility medical record was reviewed. Resident 1 was admitted to the facility on [DATE], with a diagnosis which included rhabdomyolysis (breakdown of muscle tissue that releases damaging protein into the blood), heart failure (heart does not pump blood well), hypertension ((force of blood against the artery wall is too high) and dementia (group of conditions which impairs memory loss and judgement). A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a thorough assessment of the wounds and notification to the physician after a change of condition was identified for one of three sampled residents (Resident 1). This failure has the potential to result in worsening of the pressure injuries (skin or soft tissue injuries that form due to prolonged pressure exerted over specific areas of the body), acquired by Resident 1, resulting in infection and a decline in health. Findings: On July 23, 2024, at 9:34 a.m., an unannounced visit was conducted at the facility to investigate a quality-of-care issue. A review of Resident 1's medical record indicated initial admission was on July 2, 2023, with diagnosis which included fracture of right femur (thigh bone), glaucoma (eye condition that can cause blindness), hypertension (force of the blood against the artery walls is too high), heart failure (heart does not pump blood well), Covid 19 (caused by a virus which can be contagious and spread quickly),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 proper infection control measures were implemented to prevent the spread of COVID-19 (coronavirus-an illness caused by a virus that can spread from person to person), when: 1. A Certified Nursing Assistant (CNA) did not wear face shield during care of resident who tested positive for COVID-19 and was under isolation/droplet precaution room (a room where patient is placed after being confirmed or suspected with infection with germs that can be spread to others by speaking, sneezing, or coughing). In addition, this CNA did not discard N95 (NIOSH approved respirator mask) mask after caring and/or exiting resident's room in isolation/droplet precaution room, and used the same N95 mask when caring to a non-COVID positive residents; 2. Multiple nursing staff was not able to verbalize proper use and disposal of PPEs (Personal Protective Equipments) when caring for residents in the isolation/droplet precautions room. These failures have…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 physician was notified when one of the three sampled residents (Resident 1), refused a medication ordered by the physician. Resident 1 refused lactulose ( medications used to treat constipation and used to treat or prevent certain conditions of the brain that are caused by liver failure) three times when it was ordered by the physician on February 27, 2024. This failure has the potential to result in the physician not being aware of the resident's condition which could affect the treatment plan for Resident 1. Findings: On April 18, 2024, at 9:51 a.m., an unannounced visit to the facility was conducted to investigate a quality care issue. A review of Resident 1's medical records indicated she was admitted on [DATE], and transferred to the hospital on March 1, 2024, with diagnoses which included effusion (an abnormal collection of fluid in hollow spaces or between tissues of the body) of the right knee, age-related osteoporosis (causes bones…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 laboratory (lab) tests were completed as ordered by the physician, for one of three residents reviewed (Resident 1). The physician ordered for a stat (without delay) laboratory work up on March 1, 2024, were not completed. This failure had the potential to result in a delay of diagnosis and necessary treatment for Resident 1. Findings: On April 18, 2024, at 9:51 a.m., an unannounced visit to the facility was conducted to investigate quality care issues. A review of Resident 1 ' s medical records indicated she was admitted on [DATE], and transferred to the hospital on March 1, 2024, with diagnoses which included effusion (an abnormal collection of fluid in hollow spaces or between tissues of the body) of the right knee, age-related osteoporosis (causes bones to become weak and brittle) chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs), severe protein-calorie…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medical records reflected the reasons why medications were ordered by the physician for one of the three sampled residents (Resident 1). The medical record reflected two medications (lactulose and dicyclomine) were ordered by the physician on February 27, 2024. This failure has the potential for the medical records not to fully reflect an accurate status of Resident 1's treatment while at the facility. Findings: On April 18, 2024, at 9:51 a.m., an unannounced visit to the facility was conducted to investigate a quality care issue. A review of Resident 1 ' s medical records indicated she was admitted on [DATE], and transferred to the hospital on March 1, 2024, with diagnoses which included effusion (an abnormal collection of fluid in hollow spaces or between tissues of the body) of the right knee, age-related osteoporosis (causes bones to become weak and brittle), chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure physician orders were followed for two (Resident A and Resident B) out of six residents. This failure delayed care for for Resident A and Resident B and had the potential to cause further complications with their existing comorbidities (two or more diseases or medical conditions in a patient). Findings: On March 20, 2024, at 10:15 a.m., an unannounced visit was made to the facility for an investigation of two complaints. A review of Resident A ' s medical record indicated Resident A was admitted to the facility on [DATE], with diagnoses which included a fractured (broken bone) left femur (large leg bone), hypertension (blood pressure higher than 130/80), hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone), and hyperlipidemia (high levels of fat particles in the blood). A physician order, dated October 15, 2023, indicated Resident A was to receive Foley Catheter (a type of tube, drainage…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 discharge plan was discussed with the resident and resident representative prior to discharge from the facility, for one of three residents reviewed (Resident A). This failure had the potential for Resident A to be discharged /transferred unsafely and could lead to worsening of the resident's overall condition. Findings: On February 16, 2024, at 5:30 p.m., an unannounced visit to the facility was conducted for the investigation of a complaint. On February 16, 2024, a review of Resident A's medical record, indicated Resident A was admitted to the facility on [DATE], with diagnoses which included fracture of the left femur (broken hip), myocardial infarction (heart attack), Diabetes Mellitus (a condition in which the body has trouble controlling blood sugars). A review of Resident A's Minimum Data Set (MDS - an assessment tool), dated February 8, 2024, indicated the following: - Resident A had a BIMS (Brief Interview of Mental Status) score of 8…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 conduct respirator fit testing for four of four sampled staff members (Certified Nursing Assistants [CNA] 1 and 2; Treatment Nurse [TN]; and Licensed Vocational Nurse [LVN] 1) in accordance with the facility policy and procedure. This failure had the potential for employees and a vulnerable population to be exposed to COVID-19. Findings: On February 23, 2024, at 11:44 a.m., an interview was conducted with the Infection Preventionist, (IP). The IP stated that fit testing N-95 FFR is done annually. The IP stated that all staff are required to wear a N-95 FFR currently. On February 23, 2024, at 1:06 p.m., observed CNA 2 with a visible beard protruding between the sides of N-95 filtering facepiece respirator (FFR - filtering facepiece respirator - a disposable half-mask that covers the user's airway [nose and mouth] and offers protection from particulate materials) on bilateral cheeks, a N-95 filtering facepiece respirator. On February 23, 2024, at 1:06 p.m., an interview was conducted with CNA 2. CNA 2 stated he…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 appropriate infection control practices in preventing the transmission of the coronavirus infection (Covid-19-illness caused by a virus that can be transmitted from person to person) were implemented in accordance with the facility's policy and procedure and Center for Disease Control (CDC) guidelines. The facility also failed to maintain an infection control program designed to screen and prevent the development and transmission of disease and infection of staff and residents, when: (1) One of three sample residents' ( Resident 1) room did not have a signage for transmission-based precaution (TBP-infection-control precautions in health care) and personal protective equipment (PPE-equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) for staff and visitors. (2) Two of four sampled staff did not have documented screening of tuberculosis (TB-a potentially serious infectious disease that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the facility employees had a current active CPR (a lifesaving procedure used to restart a person's heartbeat and breathing after one or both have stopped) when one of the four sampled facility employees had expired CPR certifications. This deficient practice had the potential for facility residents to receive emergency care that was not up to date leading to resident harm and/or death. Findings: On February 8, 2024, at 11:07 a.m., an unannounced visit was conducted at the facility to investigate a complaint for infection control, accidents and nursing services issue. A review of CNA 2's (Certified Nursing Assistant) employee file indicated CNA 2 was hired by the facility on [DATE].The copy of CNA 2's CPR certification located in the file indicated to renew by [DATE].There was no documented evidence that CNA 2 had a current, active CPR certification. On February 8, 2024, at 2:31 p.m., during a concurrent interview and record review with the DSD…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to report an allegation of mistreatment, and abuse, involving Resident 1, to the California Department of Public Health (CDPH), immediately but not later than 2 hours after the allegation was made. The facility was made aware of the allegation on November 3, 2023. This failure has the potential for the allegation not to be investigated which placed the other residents at risk for abuse. Findings: On December 1, 2023, at 8:35 a.m., an unannounced visit was made to the facility for the investigation of a complaint regarding resident abuse. On December 1, 2023, Resident 1's facility medical record was reviewed. Resident 1 was admitted to the facility on [DATE], with a diagnosis that included cellulitis (is infection of the skin causing swelling, pain and warm to the touch) of right upper limb, difficulty walking, need for assistance with personal care, hypertension (force of blood against the artery wall is too high), anxiety disorder (mental health disorder…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of three residents, (Resident 3) ' s environment was free from hazards to prevent falls, when Resident 3 ' s bed was high off the ground. This failure had the potential for Resident 3 to have an injury if she fell out of bed. Findings: On July 3, 2023, at 11:09 a.m., an unannounced visit to the facility was conducted to investigate a quality care issue. On July 3, 2023, at 12:04 p.m., observed Resident 3 in bed. Resident 3 ' s bed was pushed up against the wall, and her bed was high off the ground. On July 3, 2023, at 12:04 p.m., an interview was conducted with Resident 3. Resident 3 stated she had a fall while trying to get out of bed without assistance. On July 3, 2023, at 12:19 p.m., an interview was conducted with the Registered Nurse, (RN), at Resident 3 ' s bedside. The RN stated that Resident 3 ' s bed was high and should be lower to the ground. A review of Resident 3 ' s medical record indicated she was admitted to the…

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

Based on observation, interview and record review, the facility failed to ensure food was prepared, stored, served, or distributed in accordance with professional standards of food service safety when: 1. The ice machine was not cleaned and sanitized properly per manufacturer's guidelines; 2. There were various sizes of metal sheet pans stacked wet and stored in the dry area; 3. Two Dietary Aides (DA) did not perform handwashing in-between tasks; 4. The dietetic services did not have a system for thawing frozen meats; 5. The microwave for resident's food in the nourishment room located in Nursing Station 3 was dirty; 6. Resident's food was not stored at safe temperatures in the nursing station refrigerators; 7. There were several expired food and beverage items found in the resident's food refrigerator in Nursing Station 3; 8. There were several undated food items found in the resident's food refrigerators in Nursing Stations 3 and 4; 9. One DA was not unable to verbalize the correct manual dishwashing procedure; and These failures had the potential to result in cross-contamination…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the trash container lids were kept securely covered to prevent the potential attraction of pests and vermin (nuisance animals that could spread diseases). This failure had the potential for attracting insects and vermin, which could result in food-borne illnesses in a highly susceptible population of 140 residents. Findings: On March 20, 2023, at 11:24 a.m., during an initial tour of the kitchen, a concurrent observation and interview with the Registered Dietitian (RD) was conducted. Three garbage bins were observed located outside the kitchen in an enclosed area. The RD identified one out of three garbage bins for the regular trash (refuse) was uncovered when one of the two lids intended to cover the trash bin was observed to be open. She stated both lids for the recycle bins were kept open. The RD stated all garbage bins should have been covered and the garbage bin lids should have been closed to prevent pests and vermin. The facility's policy and procedure titled, Food-Related Garbage and Refuse…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 copy of the Advance Directive (AD - written statement of a person's wishes regarding medical treatment) was available in the resident's record, for three of 20 residents reviewed for AD (Residents 1, 91, & 235). This failure had the potential for Residents 1, 91, and 235's AD to not be readily retrievable by the staff and the physician, making them unaware of, and unable to honor, the residents' wishes regarding their medical treatment. Findings: 1. On March 21, 2023, a review of Resident 1's record indicated Resident 1 was admitted to the facility on [DATE]. The Physician Orders for Life-Sustaining Treatment (POLST - end-of-life planning tool), dated February 6, 2023, indicated Resident 1's AD was not available. On March 21, 2023, at 10:25 a.m., a concurrent interview and record review was conducted with Licensed Vocational Nurse (LVN) 3. She stated the POLST is the AD. 2. On March 21, 2023, a review of Resident 91's record indicated Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure services provided meet professional standards of practice, for four of 140 residents reviewed (Residents 59, 74, 234 and 484), when: 1. For Resident 59, one opened and unlabeled tube of anti-fungal cream was observed on top of the resident's nightstand; 2. For Resident 74, one bottle of unlabeled Tums (medication used for heartburn) was observed on top of the resident's nightstand; 3. For Resident 484, one zip lock bag of unknown capsules and tablets was observed on top of the resident's nightstand; and 4. For Resident 234, staff left one medicine cup containing several medications at the resident's bedside table. These failures had the potential for Residents 59, 74, 484, and 234 to receive medications unsafely. Findings: 1. On March 20, 2023, at 12:21 p.m., Resident 59 was observed in bed. Resident 59 was non-verbal. One used and unlabeled tube of anti-fungal cream was observed on top of Resident 59's nightstand. On March 21,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 respiratory care was provided, for three of three residents reviewed for respiratory (Resident 7, 51, and 26) when: 1. For Resident 7, one humidifier bottle (a medical device used to increase moisture and decrease dryness of oxygen use) was undated and one nasal cannula tubing (tubing placed through the nose and connected to an oxygen machine) was undated; 2. For Resident 51, one humidifier bottle was undated; and 3. For Resident 26, the nebulizer (machine used to administer medication through inhalation) tubing was undated. These failures could place residents who use oxygen and hand held nebulizers at risk for infection. Findings: 1. On March 21, 2023 at 12:57 p.m., Resident 7 was observed sitting on the bed using oxygen at 2 liters per minute (LPM - unit of measurement) via nasal cannula. The nasal cannula was observed connected to the humidifier bottle which was attached to the oxygen concentrator. The humidifier bottle and the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure sufficient staffing was provided for vulnerable residents in the facility, when the Direct Care Service Hours Per Patient Day (DHPPD - the actual hours of work performed per patient day by a direct caregiver) on multiple dates from February 23 to March 21, 2023, was below the state-mandated minimum requirement of 2.4. This failure had the potential for residents' needs to not be met and could affect the quality of care provided to the residents. Findings: On March 20, 2023, at 9:58 a.m., an interview with Resident 484 and family member (FM) was conducted. The FM stated it took 30 to 40 minutes for the staff to answer the call light. On March 21, 2023, at 10:05 a.m., an interview with Resident 54 was conducted. Resident 54 stated, Staffing is not okay, I wait longer than twenty minutes for help. The facility is short staffed of Certified Nursing Assistant's (CNAs). On March 21, 2023, at 10:08 a.m., an interview with Resident 26 was conducted.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provision of pharmacy services met the needs of the residents when: 1. There were missing documentation of administration of controlled substances (CS) in the resident's medical record, for two of the three residents reviewed (Resident 74 and 62). This had the potential for CS misuse or abuse; 2. Discontinued medications in the medication cart that were no longer used were stored along with active medications for resident use. This had the potential for residents to receive wrong medications; 3. The thermometer in the medication refrigerator displayed 25°F (degree Fahrenheit - unit of measurement). This had the potential for residents to receive ineffective medication therapy; 4. One multi-dose vial (MDV) containing Tuberculin PPD (test agent used in the diagnosis of tuberculosis) 5 TU (test unit) per 0.1 ml (milliliter; unit of measurement) with an open date of January 27, 2023. This had the potential for inaccurate test results;…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Dietary Aides (DA) had the appropriate skill set to safely perform the daily operations of the Food and Nutrition Services Department when proper procedures for hand washing were not followed. This failure had the potential to place 137 out of 140 highly susceptible residents, who received food from the kitchen, at risk for food-borne illness. Findings: On March 20, 2023, at 9:27 a.m., an observation and concurrent interview of DA 1 was conducted. DA 1 confirmed he performed dishwashing using the dishwashing machine by himself. On March 20, 2023, at 9:40 a.m., DA 1 was observed touching the dirty dishes on the dirty side of dishwashing machine with his bare hands. DA 1 dipped his hands in the sanitizer inside the three-compartment dishwashing sink, then touched the clean dishes on the clean side of dishwashing machine with his bare hands. On March 20, 2023, at 10:33 a.m., DA 1 was observed to perform the same procedure done at 9:40 a.m. On March 21, 2023, at 9:45 a.m., an observation was conducted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the menu was followed for the therapeutic diets during the lunch meal on March 20, 2023, and March 21, 2023, when: 1. One resident (Resident 53) with Minced/Moist, RCS (restricted concentrated sweet), Low fat/Low Cholesterol, NAS (no added salt - no salt packet on meal tray) diet did not receive yellow cake. 2. One resident (Resident 74) with Regular RCS, NAS, double protein diet got one slice of barbeque pork instead of two slices. 3. Two residents (Residents 10 and 52) who had orders for one bottle of Boost Plus (a nutritional drink to help gain or maintain weight) with their meals, had substitutions of one carton of healthshake. 4. One resident (Resident 61) with puree, fortified, high protein diet, did not receive 8 (eight) oz (ounce - unit of measurement) of milk as indicated in diet manual. 5. Seven residents (Residents 7, 434, 58, 23, 15, 436, and 435) received bone-in pork chop instead of barbeque pork as indicated in the menu. These failures had the potential to compromise the medical 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 accommodate the food preferences, for three out of 137 residents, when: 1. Resident 9 who was on puree (smooth, creamy pudding like texture)/fortified (containing added nutrients)/high protein/RCS (diabetic) diet with tray instructions of applesauce, pudding, mashed potato with meal, did not receive pudding; 2. Resident 86 who was on Regular Liberal Renal (low sodium, phosphorus, and protein) diet and preferred a Chef's salad with onion and no tomato, received a Chef's salad with tomato and no onion; and 3. Resident 20 who was on Regular RCS diet and preferred sugar-free pudding with meal, did not receive sugar-free pudding. These failures had a potential to result in decreased food intake and weight loss. Findings: 1. On March 20, 2023, starting at 12:10 p.m., an observation of the lunch meal service was conducted. Resident 9 had tray instructions which included applesauce, pudding, and mashed potato with meal. Resident 9 did not receive any pudding on her tray. On March 20, 2023, at 12:20 p.m., a Licensed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the resident was treated with dignity and respect, for one of one resident reviewed for dignity (Resident 1), when the resident waited to be fed and the Certified Nurse Assistant (CNA) 1 was observed standing while feeding the resident. This failure had the potential for Resident 1 to not attain his highest practicable physical and psychosocial wellbeing. Findings: On March 20, 2023, at 2:05 p.m., CNA 1 was observed to serve Resident 1's lunch tray and started to assist the resident for meal. On March 20, 2023, at 2:08 p.m., CNA 1 was observed to stopped assisting Resident 1 and helped in delivering the other residents' meal trays. On March 20, 2023, at 2:30 p m. Resident 1 was observed to have stopped eating and was just looking at his food, waiting for someone to assist him. Then CNA 1 came back to feed Resident 1. CNA 1 was observed to be standing while feeding Resident 1. In a concurrent interview with CNA 1, she stated Resident 1 required to be fed during meals. On March 20, 2023, at 2:45 p.m.,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 midodrine (medication used to treat low blood pressure) was administered appropriately according to the physician's order, for one of 28 residents reviewed (Resident 234), . This failure had the potential for Resident 234 to receive unnecessary medication. Findings: On March 22, 2023, Resident 234's record was reviewed. Resident 234 was admitted to the facility on [DATE], with diagnoses which included hypotension (low blood pressure). A review of Resident 234's record titled, Order Summary Report, included a physician's order, dated March 15, 2023, which indicated, .Midodrine HCl (hydrochloride) Oral (taken by mouth) Tablet 5 (five) MG (milligram - a unit of measurement) Give 1 (one) tablet two times a day for hypotension hold for sbp (systolic blood pressure - the top number is the maximum pressure the heart exerts while beating) above 120 . A review of Resident 234's record titled, Medication Administration Record (MAR), for the month of March…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 documentation of every effort made to try non-pharmacological intervention and had failed was provided prior to initiating an antipsychotic medication, for one of five residents reviewed for unnecessary medication (Resident 40). This had the potential for Resident 40 to receive unnecessary psychotropic medication. Findings: On March 23, 2023, Resident 40's medical record was reviewed. Resident 40 was admitted on [DATE], with diagnoses which included dementia (memory loss). The psychiatric consult note dated, April 13, 2021, indicated: .Patient is alert and oriented to self only. Patient thinks year is 2012. She doesn't know why she is at SNF (skilled nursing facility). Patient denies anxiety and depression. Denies AVH (audio verbal hallucination) .According to nurse patient is easily agitated and restless when staff puts patient in a chair or recycliner [sic.].When she is in bed, she is calm and peaceful . The Progress Note, dated April 16,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medication error rate for medication pass observation did not exceed five percent (%). The medication error rate was 6.9% . Findings: On March 22, 2023, at 8:15 a.m., during medication administration observation, Licensed Vocational Nurse (LVN) 5 was observed to prepare and administer the following: 1. One dose of chewable aspirin (medication used for pain) 81 milligram (mg - unit of measurement) for Resident 70. Resident 70's record was concurrently reviewed. Resident 70's record included a physician's order on June 27, 2020, for aspirin EC (enteric coated; special coating on the drug tablet to protect the stomach) tablet Delayed Release (drug absorption is delayed to protect the stomach) with the direction to give 81 mg by mouth one time a day related to cerebral infarction (stroke). Resident 70's electronic medication administration record (EMAR) indicated the same medication with the same direction was given to the resident daily in March 2023. On March 22, 2023, at 2:05 p.m., during an interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure: 1. There was a written date on the vial of Novolin R (fast acting regular insulin for control of blood sugar) to indicate when it was removed from the medication refrigerator and stored in the medication cart at room temperature; and 2. The medication bottle was properly labeled in accordance with the facility's policy and procedure. These had the potential for less effective, expired medication to be administered to the resident. Findings: On [DATE], at 4:05 p.m., during an inspection of the medication cart in Nursing Station 3 with LVN 8, a 10-ml injectable multi-dose vial (MDV) containing Novolin R (fast acting regular insulin for control of blood sugar) was observed stored at room temperature in the medication cart with no indication when it was placed in the medication cart. In a concurrent interview with LVN 8, she acknowledged the Novolin R vial was stored in the cart at room temperature. LVN 8 was not able to tell when the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident was assessed for the need to offer influenza and pneumococcal vaccines upon admission, for one of five residents reviewed for influenza and pneumococcal immunizations (Resident 42). This failure had the potential for the resident to acquire influenza infection and pneumonia infection. Findings: On March 23, 2023, Resident 42's record was reviewed. Resident 42 was admitted to the facility on [DATE]. There was no documented evidence influenza and pneumococcal vaccines were offered to Resident 42 on admission. On March 22, 2023, at 1:51 p.m., during an interview with the Infection Preventionist (IP), she stated that when a resident was admitted , the admitting nurse would inquire about the resident's vaccination status or search the vaccination status on the state's vaccination information. If the resident is eligible for the influenza or pneumococcal vaccine, the vaccines would be offered and given to the resident as soon as possible. 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, for one of five residents reviewed for immunizations (Resident 3), to notify Resident 3's representative (RR) when a new case of COVID-19 (Corona virus disease 2019- a respiratory disease caused by a virus that can be transmitted from person to person) was identified in the facility. This failure had the potential to negatively affect the physical, mental, emotional, and well-being of residents, their representatives and their families and could potentially impact resident's quality of life related to a possible exposure to COVID-19. Findings: On March 22, 2023, at 1:51 p.m. during an interview with the Infection Preventionist (IP), she stated the Administrator or designee would inform the RR or family member no later than 5 p.m. the following day when there was a new case of COVID-19 identified in the facility. The IP stated they had a recent case of a staff testing positive for COVID -19 on February 23, 2023. The IP stated all the residents currently…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 COVID-19 (Corona virus disease 2019- a respiratory disease caused by a virus that can be transmitted from person to person) vaccine was offered on admission, for one of five residents reviewed for COVID-19 immunization (Resident 42). This failure had the potential to result in Resident 42 not getting the full protection against the COVID-19 virus. Findings: On March 22, 2023, a review of Resident 42's record was conducted. Resident 42 was admitted to the facility on [DATE]. Resident 42's immunization record indicated she received the first dose of COVID-19 (Moderna) on February 10, 2021, and received the second dose on March 10, 2021. Resident 42 did not receive any COVID-19 booster dose. On March 22, 2023, at 1:51 p.m., during an interview with the Infection Preventionist (IP), she stated when a resident was admitted , the admitting nurse would inquire about the resident's vaccination status or search for the resident's vaccination status…

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