Dept Of State Hospitals - Metropolitan SNF

Based on interview and record review, the facility failed to maintain an effective abuse and neglect training program for 13 of 116 skilled nursing employees (Licensed Psychiatric Technician [LPT] 1, LPT 2, LPT 3, LPT 4, LPT 5, LPT 6, LPT 7, LPT 8, LPT 9, Registered Nurse [RN] 4, RN 5, RN 6 and RN 7), when employee abuse and neglect training was not completed annually.This failure had the potential for abuse and neglect to go unnoticed and/or not reported by the staff.Findings:During a concurrent interview and record review on 12/8/25 at 10:10 a.m. with Supervising Registered Nurse (SRN 1), the employee Recognizing and Reporting Abuse Neglect training records were reviewed. The records indicated the following:1. LPT 1's annual abuse training last completed 5/21/24.2. LPT 2's annual abuse training last completed 10/12/21.3. LPT 3's annual abuse training last completed 9/28/24.4. LPT 4's annual abuse training last completed 10/24/24.5. LPT 5's annual abuse training last completed 9/29/24.6. LPT 6's annual abuse training last completed 11/15/24.7. LPT 7's annual abuse training last…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to honor a resident's expressed desire for privacy and dignity for one of 21 sampled residents (Resident 10) when Licensed Psychiatric Technician (LPT 2) denied Resident 10 privacy during medication administration.This failure resulted in Resident 10 being exposed in view of other residents.Findings:During a review of Resident 10's Face sheet (demographics), the Face sheet indicated Resident 10 was admitted to the facility on [DATE], with a diagnosis of type 2 diabetes mellitus (condition when the body cannot use insulin correctly and sugar builds up in the blood).During an observation on 12/2/25 at 11:51 a.m., in Unit 404's Day Hall, Resident 10 was sitting in a wheelchair at a table with a food tray in front of him and there was a total of six other residents in the Day Hall. LPT 2 wheeled the medication cart over to Resident 10 and informed Resident 10 that he needed insulin (crucial hormone produced by the pancreas that regulates blood…

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

Based on interview and record review, the facility failed to assess and submit accurate data for two of 21 sampled residents (Resident 1 and 21) when the Minimum Data Set (MDS- federally required assessment tool used to guide resident care) did not reflect Resident 1 and Resident 21's current status.This failure resulted in the transmission of inaccurate data to the Centers for Medicare and Medicaid Services (CMS).Findings:During a concurrent interview and record review on 12/3/25 at 3:09 p.m. with the Minimum Data Set Coordinator (MDSC), Resident 21's MDS 3.0 Section I- Active Diagnoses, dated 10/4/25, and Active Orders, dated 11/26/25, were reviewed. Resident 21's MDS 3.0 Section I- Active Diagnoses indicated under infections Resident 21 had an active diagnosis of viral hepatitis (an infection that damages the liver). Resident 21's Active Orders indicated there was no treatment for viral hepatitis. The MDSC stated Resident 21 was diagnosed with hepatitis C in 2015 and has not received any treatment for hepatitis while residing at the facility. The MDSC confirmed Resident 21's MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure services provided met professional standards of practice when:1.Three of three licensed nurses (Licensed Psychiatric Technician [LPT] 10, LPT 11, LPT 12) inaccurately completed skin assessments for Resident 30.This failure had the potential to result in delayed wound healing and unidentified new wounds.2.Licensed Vocational Nurse (LVN 1) administered Trazadone (a prescription antidepressant medication) to Resident 29 by mouth, instead of crushed via G-tube (surgically placed tube into the stomach for feeding, medication, or drainage) as ordered by the physician.This failure had the potential to result in Resident 29 aspirating (accidentally inhaling food, liquids, particulates into the lungs).Findings: 1.During a review of Resident 30's Minimum Data Set (MDS- federally required assessment tool used to guide resident care), dated 9/3/25, the MDS indicated Resident 30 was admitted to the facility on [DATE], with a diagnosis of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the environment remained free from accidents for one of 21 sampled residents (Resident 51), when the net zipper of Resident 51's enclosure bed (specialized bed with mesh walls that zip closed around a resident to prevent falls) malfunctioned and Resident 51 got up from bed and fell on the floor.This failure had the potential for serious injury.Findings:During a review of Resident 51's Face Sheet (demographics), dated 9/2/25, the face sheet indicated Resident 51 was admitted on [DATE] with diagnoses that included neurocognitive disorder (problems with thinking and memory caused by changes or damage in the brain), epileptic seizures (when the brain briefly loses control of normal activity, leading to sudden changes in movement, behavior, or awareness) and a history of traumatic brain injury.During a review of the facility's Interdisciplinary Note, documented by the Registered Nurse (RN 11), dated 11/26/25 at 9:07 a.m., the Interdisciplinary Note…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 consistent with professional standards of practice for two of 21 sampled residents (Resident 9 and Resident 10) when:1.Resident 9's oxygen order did not specify amount or frequency of oxygen to be administered.2.Resident 10's CPAP (Continuous Positive Airway Pressure- machine that delivers pressurized air through a mask to keep airways open during sleep, prevents breathing pauses and improves oxygen levels), machine was not cleaned or maintained for over six months.3.Resident 10's oxygen concentrator humidifier (small, water-filled bottle attached to an oxygen machine which adds moisture to oxygen therapy for comfort), was not changed in 4 days.These failures had the potential to result in respiratory complications, equipment malfunction, and reduced effectiveness of prescribed therapy for the residents.Findings: 1.During a record review of Resident 9's Face Sheet (demographics), the face sheet indicated Resident 9 was…

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

Based on observation, interview and record review, the facility failed to ensure three of 16 sampled residents' (Resident 15, Resident 32 and Resident 49) medical records were complete when:1.For Resident 32, the staff did not document on the Repositioning Schedule.2. For Resident 15, the staff did not document on the Repositioning Schedule. 3.The Medication and Treatment Record (MTAR) for Resident 49 had missing entries. These failures had the potential to negatively affect the plan of care related to the specific care being provided and monitored. Findings: 1. During an observation on 1/20/2026 at 12:10 p.m. in Resident 32's room, a Repositioning Schedule form was observed posted at the wall next to Resident 32's bedside. During a review of Resident 32's Repositioning Schedule Form dated 1/20/2026, the form indicated there was no repositioning entry on the form from 12 a.m. to 5 a.m. Further review of the form indicated, Directions: At least every 2 hours while in bed, resident's position should be changed, place your initials in the column noting which position the resident is…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 policy and procedure in reporting allegations of abuse for one of three sampled residents (Resident 2), when Resident 2 reported an allegation of physical and sexual abuse to the Psychologist and this was not reported immediately after the allegation was made to the required designee's and authorities, including the state survey agency (CDPH, California Department of Public Health). This failure resulted in the delay of the investigation process and the potential in leaving Resident 2 and other residents unprotected from abuse.Findings:During a review of Resident 2's Face sheet (demographics), dated 9/23/2025, the Face sheet indicated Resident 2 was admitted on [DATE], with a diagnosis of Schizoaffective disorder, bipolar type (mental health condition that combines schizophrenia and mood disorder symptoms).During a review of Resident 2's Quarterly Psychology Progress Note (QPPN), dated 9/2/2025, completed by the Psychologist, the progress note…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 complete an annual performance evaluation on Psychiatric Technician (PT 1) for eight years. This failure had the potential to prevent PT 1 and other employees from acquiring the necessary skills to meet their job expectations.Findings:During a concurrent interview and record review on 9/23/2025 at 2:15 p.m. with the Staff Services Manager HR (SSMHR), PT 1's employee file was reviewed. PT 1 was hired in November 2017 and never had an employee performance evaluation completed. SSMHR stated there should have been eight employee performance evaluations for PT 1 and it was not normal for the evaluations to be missing. SSMHR further stated the performance evaluations were to be completed annually.During an interview on 9/25/2025 at 11:37 a.m. with the Unit Supervisor (US), US confirmed she did not complete any performance evaluations for PT 1. US stated, it was an oversight. US further stated performance evaluations were necessary to provide feedback and education to an employee.During a review of the facility's policy 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 interviews and record review, the facility failed to ensure medical records were complete and accurately documented for one of three sampled residents (Resident 1), when Resident 1's leaking Gastrostomy-tube (G-Tube - feeding tube the provides nutrition to people who cannot eat or swallow safely) assessment was not documented. This failure had the potential to negatively affect Resident 1's care. Findings: During a record review of Resident 1's Treatment Plan, dated 11/26/24, the record indicated Resident 1 was admitted to the facility on [DATE] with a history of diagnoses that included: schizophrenia (chronic mental disorder characterized by significant disruptions in thought processes, perceptions, emotions, and social behaviors), end stage renal disease (medical condition where the kidneys permanently stop functioning), essential (primary) hypertension (high blood pressure with no identifiable cause), heart failure (chronic condition where the heart does not pump blood as well as it should), and type…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facility record review, the facility failed to have a written Quality Assurance Performance Improvement (QAPI - a program that enables the facility to evaluate and improve the quality of Resident care and services through data collection, staff input, and other information) plan in place that identified areas of improvement for the Skilled Nursing units. This failure resulted in an ineffective QAPI program that did not identify systemic problems in the Skilled Nursing units related to infection prevention and enhanced barrier precautions (EBP- use of gown and gloves during high contact resident care activities, designed to reduce spread of infections) (cross reference F 880 and F 945). Findings: During an interview on 11/8/24 at 8:49 AM with Supervising Registered Nurse (SRN) 3, SRN 3 stated, when asked for a copy of their QAPI plan, We do not have a QAPI plan. During an interview on 11/8/24 at 9:02 AM with SRN 3, SRN 3 stated there was no QAPI plan for the Skilled Nursing units. SRN 3 stated that they had the capability to track and trend based on program 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 ensure the Quality Assessment and Assurance (QAA) committee had the required members in attendance. This failure had the potential for quality care improvement activities related to Infection Control to not be evaluated and revised as needed and the potential to negatively impact the quality of resident care. Findings: During a concurrent interview and record review on 11/8/24 at 9:35 AM with the Standards Compliance Director (SCD), the SCD reviewed the Quality Council Minutes from the 9/5/24 meeting. SCD acknowledged the Infection Preventionist/Public Health Nurse II for the Skilled Nursing unit was not in attendance. During a record review of the Quality Council Minutes from 4/23/24, the record indicated that the Infection Preventionist/Public Health Nurse II was not in attendance. During a review of the facility's Policy and Procedure (P&P) titled, Risk Management, dated 7/8/24, the P&P did not indicate the Infection Preventionist as a required member of Quality Council (QC) under section 4.3.1.1 Quality Council…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an infection prevention and control program designed to help prevent the transmission of communicable diseases and infections for six of 22 sampled residents (Residents 7, 36, 1, 35, 11 and 54) when: 1. The trash and linen carts were placed outside of Resident 7's isolation room. 2. Psychiatric Technician (PT) 2 accepted a pitcher handed by Resident 7, who was on isolation precautions, with bare hands. 3. Registered Nurse (RN) 7 performed wound care to Resident 36 wearing gloves as the only personal protective equipment (PPE) used. 4. PT 1 performed wound care to Resident 1 wearing gloves as the only PPE used. 5. Psychiatric Technician Assistant (PTA) 2 and PTA 3 changed Resident 35's linen and provided personal hygiene without wearing a gown. 6. RN 5 and RN Shift Lead (RNSL) 2 performed a dressing change for Resident 11's pressure injury (chronic wound to the skin and underlying tissues) to his left buttock without wearing 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 maintain an effective infection control training program for 94 of 94 staff when the facility did not develop a written policy and training for staff regarding Enhance Barrier Precautions (EBP- use of gown and gloves during high contact resident care activities, designed to reduce spread of infections). (cross reference to F880) This failure had the potential to negatively affect the facility's ability to maintain a safe environment to prevent the spread of infectious diseases among the 54 residents in the facility. Findings: During an observation on 11/4/24 at 1:10 PM in the hallway by Resident 36's room, the hallway was clear. There was no personal protective equipment (PPE) cart or EBP signage by the door. During a review of Resident 36's clinical record titled, Treatment Plan, dated 10/31/24, the treatment plan indicated, . MEDICAL PROBLEMS . 15. Left Buttock Pressure Injury [a localized area of skin damage caused by prolonged pressure on skin] Unstageable [extent of injury cannot be determined] . 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 residents were treated with dignity and respect for two of 12 sampled residents (Residents 13 and 357) when: 1. Registered Nurse (RN) 3 was standing while feeding Resident 13 in bed. 2. Registered Nurse (RN) 1 was standing while feeding Resident 357 in the dining room. These failures resulted in Resident 13 and Resident 357 not being provided a respectful and dignified dining experience. Findings: 1. During an observation on 11/4/24 at 1:06 PM in Resident 13's room, Resident 13 was in an enclosure bed with head of bed up. Resident 13 was nonverbal and unable to communicate needs. Resident 13 was being fed by Registered Nurse (RN) 3 while standing. RN 3 was not at Resident 13's eye level. Resident 13's gaze was on the chest level of RN 3. During an interview on 11/4/24 at 1:24 PM with RN 3, RN 3 stated, I have to have a chair . sitting in front of the patient. RN 3 stated he should be at eye level of Resident 13. RN 3 stated, Standing over [resident] is intimidating. RN 3 stated standing while feeding…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 22 sampled residents (Resident 357 and Resident 26) had their call lights within reach. This failure had the potential to result in Resident 357 and Resident 26 not having their needs met. Findings: 1. During a review of Resident 357's Clinical Record, the record indicated that Resident 357 was admitted to the facility on [DATE] with a history of diagnoses that included Schizoaffective disorder, Bipolar type (a rare mental health condition that involves both schizophrenia symptoms and bipolar disorder symptoms), and major neurocognitive disorder (a decline in mental function caused by a medical condition, rather than a psychiatric illness) due to traumatic brain injury (Brain dysfunction caused by an outside force, usually a violent blow to the head). During a concurrent observation and interview on 11/4/24 at 1:56 PM with Resident 357, in Resident 357's room, observed Resident 357 laying in a enclosure bed, call light…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observations, interview, and record review, the facility failed to provide tube feeding (liquid nutrition delivered using a feeding pump directly into the stomach) per the doctor's order for one of two sampled residents (Resident 26). This failure had the potential to result in weight loss and complications of tube feedings for Resident 26. Findings: During an observation on 11/6/24 at 8:57 AM in Resident 26's Room, Resident 26 was observed with a gastrostomy tube (GT - a tube inserted through the skin directly into the stomach for liquid nutrition). Resident 26's tube feeding pump was alarming and not providing tube feeding at that time. The tube feeding was attached to a feeding pump set to deliver 60 milliliters (milliliter (ml) is approximately 2 ounces) of liquid nutrition per hour. The label on the tube feeding bag indicated the feeding was started on 11/6/24 at 12 AM and was to infuse for 22 hours. During a concurrent observation and interview on 11/6/24 at 11:14 AM with Registered Nurse Shift Lead (RNSL) 2 in Resident 26's room, Resident 26's tube feeding pump was…

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

Based on observation, interview, and record review, the facility failed to ensure food service safety and sanitation requirements were met when: 1. Food trays were observed unclean, chipped and with brownish, yellowish stains. 2. Expired foods were found in dry warehouse, freezer and food storage area. 3. One dented can was found in dry warehouse. 4. One heavily marred chopping board was in the food preparation area. These failures had the potential to cause food borne illness among vulnerable residents. Findings: 1. During a concurrent observation and interview on 11/4/24 at 11:58 AM with Dietetics Director (DD) in the clean tray area, 15 gray food trays were observed as unclean with food debris, and one food tray with an old meal ticket still attached. The trays were chipped with brown and yellowish stains. DD stated the unclean, chipped and stained trays should not be in the clean area. During review of the facility's Policy and Procedure (P&P) titled, Nutrition Policy Manual Policy Number: 3401, dated July 2018, the P&P indicated, . All kitchen and dining room utensils along…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 food storage areas in the warehouse and main kitchen clean from debris and garbage. This failure had the potential to result in food borne illness in vulnerable residents. Findings: During a concurrent observation and interview on 11/4/24 at 12:44 PM with the Dietetics Director (DD) in the warehouse, two cups of grape juice and chipped wood debris were observed on the floor. DD was observed throwing the grape juice cups away in the trash can. DD stated the trash and debris should have been cleaned out. During a concurrent observation and interview on 11/4/24 at 1:02 PM with the Assistant Dietetics Director (ADD) in the walk-in freezer, chipped wood and plastic wrappers were observed on the floor. ADD stated, it should have been cleaned out. During a review of the facility's Policy and Procedure titled, Nutrition Policy Manual Policy Number: 3401, dated July 2018, P&P indicated, .The objective is to control and remove any source of contamination and prevent the growth of bacteria: Garbage is always put…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a qualified facility approved interpreter was provided for one of three sampled residents (Resident 2 ). This failure resulted in Resident 2 being unable to communicate his needs with staff. Findings: During a concurrent observation and interview on 10/22/24 at 11:55 am with Lead Registered Nurse (LRN) 1 on Unit 404, Resident 2 was speaking Spanish to staff. LRN 1, who is not spanish speaking, stated Resident 2 was Spanish speaking and needed an interpreter. LRN 1 stated she was unaware of who the approved interpreters were for the facility. LRN 1 further stated she used either another resident or non-facility approved interpreters to communicate with Resident 2. During an interview on 10/22/24 at 12:16 pm with Registered Nurse (RN) 2, RN 2 stated he called the on-call doctor on 10/18/24 to evaluate Resident 1 when the resident complained of scrotum pain. RN 2 stated Medical Doctor (MD) 1 used Licensed Vocational Nurse (LVN) 1 to translate for Resident 2 during the evaluation. RN 2 stated, after…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interventions were implemented to prevent falls for one of three sampled residents (Resident 1). This failure resulted in Resident 1 experiencing a fall which resulted in a scalp contusion (bruise). Findings: During a concurrent observation and interview on 10/22/24 at 11:49 am with Resident 1 on Unit 404, Resident 1 had discoloration to left side of his forehead. Resident 1 stated he did not use his wheelchair when standing and fell. Resident 1 further stated he had pain to his head and nausea. During an interview on 10/22/24 at 11:29 am with Registered Nurse (RN) 1, RN 1 stated he observed Resident 1 in his wheelchair in the dayroom, approximately 15 feet from where RN 1 was sitting. RN 1 stated Resident 1 put his hands on the armrests of the wheelchair and stood unassisted, then fell forward. RN 1 confirmed he did not educate Resident 1 to stop and sit down or assist the resident with standing. RN 1 stated, I did not think he would fall. During an interview on 10/23/24 at 12:29 pm with Lead…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interventions were implemented to prevent falls for one of three sampled residents (Resident 1). This failure resulted in Resident 1 experiencing a fracture to the left fifth finger after a fall. Findings: During a concurrent observation and interview on 9/24/24 at 9:52 am with Resident 1, Resident 1 had discoloration to her left fifth finger. Resident 1 stated she did not use her walker while ambulating and fell. Resident 1 further stated she broke her left fifth finger during her fall. During an interview on 9/25/24 at 9:31 am with Registered Nurse (RN) 1, RN 1 stated Resident 1 was sitting at a table in the day room. RN 1 further stated, Resident 1 got up from the table and walked toward him, approximately 10 feet without using her walker. RN 1 confirmed he did not educate Resident 1 to stop and use her walker or assist the resident with ambulating. RN 1 stated, It was close so I did not think she would fall. During an interview on 9/25/24 at 9:58 am with Supervising Registered Nurse (SRN) 1, SRN 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 care consistent with professional standards of practice, when the Respiratory Care Practitioner (RCP) failed to follow facility policy and procedure (P&P) for tracheostomy (opening through the windpipe to the outside neck to help a person breath) care. The RCP failed to document Resident 1's assessments in his medical record. This failure had the potential for a decrease in Resident 1's quality of care, due to lack of communication between nursing and the RCP. Findings: During a review of Resident 1's face sheet (demographic), it indicated Resident 1 was readmitted to the facility on [DATE]. His diagnoses included dementia (decline in his mental status) and tracheostomy. Further review indicated Resident 1 was sent out to the hospital when his tracheostomy site was noted with maggots on 11/4/23. During a review of Resident 1's Physician orders dated 10/5/23 at 0900 [9:00 a.m.], it indicated, Trach [tracheostomy] .care at 1000 [10:00 a.m.] 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 update the nursing care plans (an individualized plan that provides direction for a resident's medical care) for four of 24 sampled residents (Residents 302, 303, 304, and 352). This failure had the potential to affect the provision of care for the residents. Findings: 1. During a review of Resident 302's clinical record, the record indicated Resident 302 was admitted to the facility on [DATE] with diagnoses of schizoaffective disorder (a mental health problem where a person experiences hallucinations and mood symptoms) and generalized muscle weakness. During a concurrent review of Resident 302's nursing care plans and an interview with MDS (Minimum Data Set, a standardized assessment) Registered Nurse 2 (MDS RN 2) on 11/29/23 at 9:44 AM, the nursing care plans were dated on 8/18/23 with a reevaluation date of 11/17/23. MDS RN 2 stated the care plans were not updated and should have been updated on 11/17/23. 2. During a review of Resident 303'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 ensure: 1. The shift lead key set and treatment cart key in Unit 404 were not found in a drawer accessible by unlicensed staff. 2. The as needed (PRN) and stat (immediate) medication cabinet was not found unlocked. 3. An expired central line tray (a kit to clean and change the dressing of an intravenous, within the vein, line) and an expired IV (intravenous, within the vein) starter kit were not found in the emergency cart in Unit 404. 4. The narcotic (controlled medication) drawer on medication cart 1 was locked during medication administration in Unit 406. These failures had the potential for unauthorized staff to have access to the medication room, for drug diversion, and expired medical supplies to be used for residents. Findings: 1. During a concurrent observation and interview with Registered Nurse 2 (RN 2) on [DATE] at 8:38 AM, RN 2 was observed retrieving keys from the nurses station. RN 2 stated he took the charge keys (shift…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 food service safety and sanitation requirements were followed when: 1. Two full trays of Cream of rice, 10 cartons of unopened non-fat milk, 26 cartons of unopened non-fat chocolate milk, and seven unopened bags of tortillas were expired. 2. Kitchen utensils (food grinder and chopping board) were found unclean. 3. Two dented cans of pureed turkey with turkey broth were kept in the storage area. 4. One container of breakfast syrup was opened and not labeled. 5. Four Dietary staff had improper use of hairnets. 6. 14 expired chicken based containers were found in the food storage areas. These failures had the potential to cause food borne illness among vulnerable residents. Findings: 1. During a concurrent observation and interview on 11/27/23 at 12:38 PM with Director of Dietetics (DD), there were two full trays of cream of rice with an expiration date of 11/26/23. The DD stated it should have been dumped yesterday. During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. During a tour conducted on 11/27/23 at 12:13 PM, in Unit 404, a quarantine safety alert and an airborne precaution signs were posted next to the entrance door of the unit. The airborne precaution sign indicated, Stop. Airborne Precaution. To prevent the spread of infections, Wash hands or use alcohol based hand sanitizer before entering and upon exiting this room. Put on an N-95 Mask/Respirator before entering this room. (Do not use a standard mask) Keep door closed at all times. During a concurrent observation and interview on 11/27/23 at 12:28 PM, with Psychiatric Technician 2 (PT 2), PT 2 was observed next to door of the day hall with a N-95 respirator mask under his chin. PT 2 stated he removed his N-95 respirator mask because he had to talk to another staff member who was inside the day hall. PT 2 stated he should not have removed his mask because the unit was under quarantine for Covid-19. During an observation on 11/27/23 at 12:33 PM, two hospital police officers (HPO) were standing by room [ROOM…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 sanitary (clean) environment for two of 24 sampled residents (Residents 251and 252) when: 1. For Resident 251, brown dried formula was observed on the bottom of Gastrostomy (GT-- a tube is inserted through the abdominal wall and into the stomach) Intravenous (IV) pole stand base (a slender portable pole with a wheeled base and hooks on top to hang GT formulas) and dirty used gloves were observed on top of Resident 251's wheelchair lap tray. 2. For Resident 252, brown dried formula was observed on the bottom of the GT IV pole stand base. These failures had the potential for an unsafe environment and increase the risk of infectious germs(potential to cause disease) to residents, staff, and visitors. Findings: 1. During a review of Resident 251's Face sheet (demographics), [undated], the Face Sheet indicated, Resident 251 was admitted to the facility on [DATE] with diagnoses including major neurocognitive disorder (decreased mental…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of 24 sampled residents (Resident 1 and Resident 357) that their call lights within reach. This failure had the potential to result in Resident 1 and Resident 357 not having their needs met. Findings: 1. During a concurrent observation and interview on 11/27/23 at 12:43 PM with Registered Nurse 7 (RN 7) in room [ROOM NUMBER]A on Unit 406, observed Resident 1's call light cord hanging outside Resident 1's posey enclosure bed (a special bed that provides a safe controlled environment for residents who are at risk for injury). RN 7 confirmed that there was no call light in reach of Resident 1's bed. RN7 stated, When it is time for the Resident to be in bed, staff will put the call light in reach. During a concurrent observation and interview on 11/29/23 at 4:26 PM with Resident 1, observed Resident 1's call light cord hanging outside of Resident's posey enclosure bed. Resident 1 stated, I have no access to my call light when I am…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 schedule and conduct monthly resident council minutes meetings (scheduled meetings where residents voice concerns and grievances to the facility) on a regular basis for fifty-two Residents on unit 404 and 406. This failure had the potential to impede the resident's rights to express their concerns, know their rights, and to socialize as a group in a universe of 52 Residents. Findings: During a concurrent interview and record review on 11/29/23 at 10:48 AM, with Program Director (PD), Unit 404 and Unit 406 Resident Council Minutes, dated 2023 were reviewed. The Resident Council Minutes indicated, there were no resident council minute meetings documented for the following months on unit 404 March, May, July, and September 2023 and Unit 406 February, March, May, and October 2023. PD stated, they should have been done once a month. During a review of facility's handbook titled, Program 6 Skilled Nursing Facility Admission, Agreement, Handbook, (undated), indicated, On at least a monthly basis, each unit in program 6 will 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 2. During an observation on 11/27/23 at 1:28 PM in Unit 406 room [ROOM NUMBER], there was dried up brown liquid, condiment packets and debris located under Resident 151's bed. There was also dried up red-orange spots on the floor around the room. During an interview on 11/27/23 at 1:35 PM with Registered Nurse 7 (RN 7), RN 7 stated, Resident 151 throws her food and coffee. RN 7 stated that housekeeping does come and clean the rooms every shift and she was not sure why the floor was so dirty. During an interview on 11/30/23 at 8:00 AM with Custodian 1 (C 1), C 1 stated, Resident rooms should be cleaned on every shift as well as whenever staff notice rooms need cleaning. C 1 stated, Cleaning involves mopping and getting under furniture, this includes moving beds and dressers. During a review of the facility's policy and procedure (P&P) titled, Cleaning Responsibilities, dated [undated], indicated, The hospital shall be clean, sanitary and in good repair at all times. Based on observation, interview and 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 their policy and procedure on the use of physical restraints (any device or equipment that restricts movement that resident cannot easily remove) for one of 24 sampled residents (Resident 401) when staff did not document Resident 401's response to the restraint and the impact of the restratin on his actiities of daily living. This failure had the potential to result in the unnecessary use of the physical restraint that could lead to the decline of the resident's physical functioning and quality of life. Findings: A review of Resident 401's Face Sheet (demographic) record indicated Resident 401 was re-admitted to the facility on [DATE], with diagnoses that included gastrostomy tube (GT- tube, inserted through a small incision in the abdomen into the stomach used for long-term enteral nutrition), tracheostomy tube (trach tube - an opening surgically created through the neck into the trachea to allow air to fill the lungs). A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of 24 sampled residents (Resident 451) received the necessary services to maintain proper personal care when Resident 451 was observed with dirty fingernails. This failure had the potential to result in Resident 451 developing an infection. Findings: During a review of Resident 451's Face Sheet (demographic) dated 11/15/23, the Face Sheet indicated Resident 451 was admitted to the facility on [DATE] with diagnosis of neurocognitive disorder (decline in mental function). During a concurrent observation and interview on 11/28/23 at 2:44 PM with Psychiatric Technician Assistant 1 (PTA 1), Resident 451 was oboserved in the Day Room placing his thumb in his mouth with black debris underneath his fingernails. PTA 1 stated Resident 451 was confused, non-verbal, and often placed his fingers in his mouth. During a review of the facility's policy and procedure (P&P) titled, Activities of Daily Living (ADLs), dated April 2020, indicated,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure interventions were implemented to prevent falls for one of 24 sampled residents (Resident 157). This failure resulted in Resident 157 experiencing an unwitnessed fall that resulted in shoulder pain and had the potential for further falls and injuries. Findings: During an observation on 11/28/23 at 12:17 PM, shouts were heard coming from room [ROOM NUMBER]. Resident 157 was observed on the floor. Resident 157 was observed wearing plain white socks that were slightly twisted around her feet. The bed was observed not in a low position. Resdient 157 stated, My elbow hurts. During an interview on 11/30/23 at 9:10 AM with Registered Nurse 8 (RN 8), RN 8 stated that per Resident she fell when ambulating from bed to wheelchair for lunch. During an interview on 11/30/23 at 9:22 AM with Resident 157, Resident 157 stated, I fell when I was trying to get into my wheelchair for lunch, and resident's bed was raised up. During an interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement the physician order for supplemental hydration (the replacement of body fluids lost through sweating, exhaling, and eliminating waste) to one of 24 sampled residents (Resident 401). This failure resulted in Resident 401 receiving less fluids than ordered and had the potential to place the resident at risk for dehydration (harmful reduction in the amount of water or fluids in the body). Findings: During a review of Resident 401's Face Sheet (demographic) dated 3/16/23, indicated Resident 401 was admitted to the facility on [DATE], with diagnoses including gastrostomy tube (tube inserted through a small incision in the abdomen into the stomach), and unspecified weight loss. During a review of Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 11/2/23, the MDS indicated Resident 401 was severely impaired in cognitive skills for daily decision making and required total assistance with all activities of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow its tracheostomy care policy and procedure and obtain a physician order for oxygen therapy when: 1. Resident 452's tracheostomy (opening at the front of the neck where a tube can be inserted into the airway to help with breathing) tie change was not performed with the two-person technique. 2. Resident 452's oxygen saturation (measure of how much oxygen is in the blood) was not assessed before, during, and after tracheal suctioning (removing secretions from the airway with a sterile catheter). 3. Sterile (free from bacteria or other living germs) gloves were not used on Resident 452's tracheostomy tie change. 4. Resident 452's tracheostomy care was not properly documented. 5. Resident 356 had oxygen therapy without a physician order. These failures had the potential to result in Resident 452 experiencing respiratory complications and inaccurate documentation of tracheostomy treatment provided, and for Resident 356 needs inaccurately…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safety requirements were followed when: 1. There were two uncovered trash cans in the tray line area. 2. There were two deformed empty grape juice containers found underneath a pallet. There were plastic wrap, paper liner, and chipped wood found in the metal container at the stockroom. These failures had the potential to cause food borne illnesses among vulnerable residents. Findings: 1. During a concurrent observation and interview on 11/27/23 at 12:13 PM with Supervising [NAME] II (SC II) at the East and [NAME] tray line area, there were two uncovered trashcans on each end of the East and [NAME] tray line. SC II stated they should have been covered. During a review of the facility's policy and procedure titled, (Name of the facility) Nutrition Policy Manual Policy Number: 3401 Subject: Infection Control, dated September 2016, indicated, . Garbage is always put into designated disposal units with lids Garbage cans have tight fitting lids . 2. During a concurrent observation and interview on…

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

Based on interview and record, the facility failed to ensure the Infection Preventionist (IP, responsible for the infection prevention and control program) completed 10 hours of Infection Prevention and Control (IPC) continuing education (CE) on an annual basis. This failure had the potential for the IP not to be updated with the latest health care associated infections information and the ability to prevent and manage the spread of infection to residents, staff, and visitors in the facility. Findings: During a review of IP's training certificate Nursing Home Infection Preventionist Training Course, dated 5/31/22, indicated, the IP obtained the certificate on 5/31/22. During an interview on 11/30/23 at 9:20 AM with Personnel Officer 1 (PO 1), PO 1 stated the IP should have completed 10 hours of IPC annually. During an interview on 11/30/23 at 3:22 PM with the Standards Compliance Director (SCD), SCD confirmed, the IP did not have 10 CE's of IPC. During a review of the All Facilities Letter (AFL) 20-84 titled, Infection Prevention Recommendations and Incorporation into the Quality…

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