Novato Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and records review, the facility failed to provide appropriate treatment and services to increase range of motion (the full distance and direction a joint, such as a knee, shoulder, or neck, can move, measured in flexibility and functionality) for one of three sampled residents (Resident 1), when Resident 1 was referred to the restorative nursing program (RNP, nursing led program in long-term care that helps residents maintain or improve their independence after formal therapy ends) but the facility failed to ensure an order had been obtained and RNP services were initiated.This failure had the potential to result in worsening of stiffening of joints of Resident 1's left hand and painful movements.Findings:A review of Resident 1's face sheet (front page of the chart that contains a summary of basic information about the resident), indicated she was first admitted to the facility on [DATE] for diagnoses including paralysis (loss of muscle control and sometimes loss of sensation) from the neck…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure two residents (Resident 2 and Resident 4) out of six sampled residents were free from physical and emotional abuse when:Resident 1 intentionally hit Resident 2 with his pillow.Resident 3 intentionally threw a full bottle of a nutritional supplement at Resident 4 which landed on Resident 4's face.These failures resulted in Resident 2 experiencing physical harm and caused Resident 4 to sustain a bruise to her left lower lip.Findings:1. A review of Resident 1's admission record indicated admission to the facility on [DATE] with diagnoses of Symptomatic Epilepsy (seizure disorder caused by an identifiable injury to the brain) and Paranoid Schizophrenia (a mental health condition where a person has a hard time distinguishing between what is real and what is imagined).A review of Resident 2's admission record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses of Hemiplegia and Hemiparesis (weakness and paralysis on one side 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 adequate supervision for one resident (Resident 1) out of a sampled 6 residents when staff were unaware that Resident 1 eloped from the facility.This failure decreased the facility's potential to prevent serious injury, harm, or death to Resident 1.Findings:A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of Aphasia (damage to the brain's language center affecting the ability to communicate) following Cerebral Infarction (stroke), Muscle Weakness, Unsteadiness on feet, and a history of falling.A review of Resident 1's Elopement Evaluation, dated 11/23/25, indicated Resident 1 had a history of elopement and wandering which flagged Resident 1 at risk for exiting the facility unnoticed.A review of Resident 1's Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 11/28/25, indicated Resident 1 completed the activity of walking 50 feet with two turns with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to meet professional standards of quality and follow its own policies when Certified Nursing Assistant 1 (CNA 1) did not immediately report an incident of falls for one of three sampled residents (Resident 1). As a result, nursing staff did not promptly complete a change of condition assessment.This incident led to a two-day delay in diagnosing Resident 1's left arm fracture possibly caused by the fall, which resulted in an unwarranted postponement of appropriate treatment and pain management for Resident 1.During a review of Resident 1's admission Record (a facility demographic), dated 12/03/25, it indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Dementia (a condition that affects memory, thinking and behavior).During a review of Resident 1's Minimum Data Set Section C (MDS-an assessment tool), dated 11/14/25, it indicated Resident 1 had a moderately impaired ability to make decisions, had both…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident (Resident 3) of four sampled residents was free from abuse when he was struck in the face by Resident 4.This failure resulted in Resident 3 sustaining a painful, sightly swollen, reddened area to his left eyebrow.A review of Resident 3's admission record indicated he was last admitted on [DATE] with the diagnoses of pressure ulcers and heart failure.A review of Resident 3's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 11/15/23, indicated Resident 3 had fully intact cognition (no issues with thinking or memory).A review of Resident 4's admission record indicated he was admitted on [DATE] with the diagnosis of Alzheimer's disease (a disease characterized by a progressive decline in mental abilities).A review of Resident 4's MDS, dated [DATE], indicated Resident 4 had severe memory impairment.A review of Resident 3's Situation, Background, Assessment, Recommendation (SBAR- a communication tool used by…

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

Based on interview and record review, the facility failed to ensure an allegation of verbal abuse was reported within the required timeframe for two residents (Resident 1 and Resident 2) of four sampled residents when the allegation was reported to the California Department of Public Health (the Department) the following day.This failure of timely reporting had the potential to cause a delayed response by enforcement agencies to ensure resident safety.A review of Resident 1's facility document titled, SBAR [Situation, Background, Assessment, and Recommendation- a tool used in healthcare settings to convey information quickly and clearly] Communication Form, dated 11/10/25 at 2:35 a.m. and signed by Licensed Nurse 1 (LN 1), indicated Resident 1 was involved in a verbal altercation with his roommate, Resident 2.A review of Resident 2's SBAR Communication Form, dated 11/10/25 at 2:35 a.m. indicated LN 1, another nurse, and 2 Certified Nurse Assistants overheard Resident 2 yelling.A review of a nursing progress note dated 11/11/25 at 5:55 p.m. indicated the Interdisciplinary Team (IDT-…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 dietary staff were trained and had appropriate competencies and skills sets for a census of 162, when: 1. DA 1 was observed not wearing a hair net while working inside the kitchen,2. DA 2 did not follow the manufacturer's instruction for the use of red bucket test strips,3. The [NAME] could not verbalize the correct Cool-down Process of Hot food, and;4. The Dietary supervisor could not provide documentation of last quarter's cool down logs for both the Hot Food cool down process, and Ambient (Shelf stable food that can be safely stored in room temperature) cool down process. These failures reduced the facility's potential to ensure dietary staff were skilled and competent to provide dietary services to the residents. Findings:During a concurrent interview and record review on 9/18/25 at 9:50 a.m. with Registered Dietician (RD)1, RD 1 confirmed she does not have any records of the competencies and documentations performed by the dietary staff related to:1. Infection Control - use of hairnets in 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 pureed (cooked food that is blended to the consistency of a cream paste) food was prepared correctly for a census of 162, when temperature of a cold pureed fruit tested at 71.8 F and was warm to taste.This failure had a potential to result in food that does not meet resident nutritional needs.Findings:During an observation on 9/17/25 at 1:55 p.m., two test trays were delivered to the conference room by the Dietary Supervisor (DS) and Registered Dietician (RD) 2 using the food cart. Two test trays consisted of: One Regular meal tray, one pureed meal tray. The temperature was checked by both RD 2 and Nurse Surveyor (NS) side by side. Food temperature test results were as follows: Pureed meal tray:Puree Tacos Casserole 124 FPuree Zucchini - 118.8 FPureed Tangy Glazed Fruit - 71.8 F The survey team sampled the pureed food and the allegedly cold pureed tangy glazed fruit tasted warm. During an interview on 9/18/25 at 9:50 a.m. with Registered Dietician (RD) 1, RD 1 stated, her expectation for the supposedly…

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

Based on observation, interview, and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety for a census of 162, when:1. Dietary Aid (DA) 1 was observed not wearing a hair net while inside the kitchen.2. Several various metal sheet pans and metal lids in clean and ready-to-use storage areas: a. Were stacked wet while stored away. b. Had food debris.3. There were bags of food items in the walk-in refrigerator and concerns related to frozen fish patties in the the walk-in freezer. a. The walk-in refrigerator floor was extremely wet b. One bag of carrot strips expired. c. One bag of open corn tortilla was not labeled with an open or use by date. d. One package of opened fish nuggets in a large 2-gallon size zipped bag had freezer burn.4. The oven had black residues at the bottom layer and was dirty.5. DA 2 could not verbalize and perform the proper process of testing for the sanitation (red) bucket. 6. [NAME] was unable to verbalize the correct technique for the cool down process for hot foods.7.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 five out of 40 sampled residents (Resident 58, Resident 135, Resident 42, Resident 116, Resident 124 and Resident 64) were treated with dignity when:Staff were feeding residents standing up and were not asking permission to wear clothes protector before mealtime during dining observationResident 64, who needed assistance with feeding was referred to as feeder. Licensed Nurse did not offer Resident 124 privacy during medication pass.These failures resulted in residents feeling rushed and undignified, caused Resident 64 to feel disrespected and had the potential to decrease his self-esteem. Findings: During a review of Resident 58's admission Record (AR), Resident 58 was admitted to the facility 11/20 with admitting diagnosis of unspecified dementia (a group of conditions that cause a decline in cognitive functions, such as memory, thinking, problem-solving, and language.) During a review of Resident 135's AR, Resident 135 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 interview and record review, the facility failed to ensure accurate documentation of the residents' wishes regarding their care was maintained for six of 40 sampled residents reviewed for Advance Directives (AD - a written instruction relating to the provision of health care when the individual is incapacitated) when: POLST (Physician's Order for Life-Sustaining Treatment) was not completed for Resident 10, and Advanced Directive were not completed or offered to Residents 13, 15, 18, 110, 122. These failures had the potential for Residents 10, 13, 15, 18, 110, 122 to not have their wishes and treatment preferences honored. Findings: A review of Resident 10's admission Record indicated Resident 10 was admitted to the facility in July 2025 with multiple diagnoses including fracture of left femur (bone of the upper leg), chronic respiratory failure (lungs are unable to exchange oxygen and carbon dioxide effectively), chronic obstructive pulmonary disease (lung disease that blocks air flow making it difficult to breathe) and dementia (impairment of brain functions causing…

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

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent when 22 medication errors were found out of 47 opportunities observed during a medication administration for three of 40 sampled residents (Resident 25 , Resident 124, Resident 46) when:1) Resident 25's prostate (male organ) medication was not given, and the wrong vitamin was administered;2) Resident 124's medications were crushed, medications were not given, and were not given according to physician orders; and3) Resident 46's blood pressure medication was not given, scheduled pain medication and morning medication were not given at scheduled time. These failures resulted in medication error rate of 46.81 percent resulting from medications not given in accordance with the prescriber's orders and had the potential to affect the residents' clinical conditions.Findings:1.During a medication administration observation on 9/18/25 at 8:50 a.m. with Licensed Nurse (LN) 6, LN 6 was preparing 7 medications for Resident 25, including Vitamin b12 1000 mg (mg-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 medications were properly stored and labeled, for a census of 162 when:1. Medications were found at nurses station and at resident bedside unattended,2. Expired and discontinued medications were available for resident use,3. Loose pills were found in the drawers and the back of medication cart,4. Discontinued narcotics found in narcotic cart and Licensed Nurses (LN) are not counting during change of shift,5. Sticky residual found on outside of multiple bottles, and;6. Non medication items were found in medication cart. These deficient practices had the potential for residents to receive unsafe or reduced potency medications from being used past their expiration dates, improper storage, and diversion or misuse of medications from not being securely stored.Findings: 1.During a concurrent observation and interview on 9/16/25 at 11:02 a.m. with Licensed Nurse (LN) 9, a medication cup with cream was found on the bedside table in 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 ensure proper infection control practices were implemented for a census of 162, when:Proper hand hygiene was not implemented during dining observation. Resident 150 has a suprapubic catheter (A suprapubic catheter is a medical device that helps drain urine from your bladder. It enters your body through a small incision in your abdomen) was not on Enhanced Barrier Precautions (EBP an infection control measures in nursing homes and similar settings to prevent the spread of multidrug-resistant organisms.) A shared blood pressure cuff was not cleaned and sanitized in between resident use.LN 4 did not properly wear N95 mask during medication pass.Multiple staff entered residents' rooms on isolation precautions without wearing the required face shields.Staff not wearing proper PPE (personal protective equipment), housekeeping staff were not familiar with chemicals used for disinfecting residents' rooms and it's dwelling time, no high-contact…

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

Based on observation, interview, and record review, the facility failed to ensure the needs were accommodated for two of 40 sampled residents (Resident 120 and Resident 140), when Resident 120's bed control remote (a handheld device that is connected by a cable to a bed and allows a person to adjust the position of a bed, elevate the head or feet) was not accessible to the resident and Resident 140's call light (a device used to contact staff for assistance) was not within the resident's reach.These failures resulted for Resident 120 and Resident 140 to experience frustration and anxiety when the residents were not able to reach bed control and a call for assistance. Findings:A review of the admission record indicated the facility admitted Resident 120 in 2017 with multiple diagnoses which included left hemiplegia (paralysis on his left side of the body). Resident 120's medical records indicated that left side was his dominant side.A review of Resident 120's care plan titled, The resident has an ADL [activities of daily living, tasks as bathing, toileting, feeding, a person performs…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 40 sampled residents (Resident 97 and Resident 172) received necessary care and services to maintain good nutrition, grooming, and personal hygiene when:Resident 97 had long, thick toenails.Resident 172 was not provided assistance with eating and personal care. These failures reduced the facility's potential to provide Activities of Daily Living (ADL) care for Resident 97 and Resident 197, and had the potential to negatively affect their self-esteem, comfort, and personal hygiene.Findings: During a review of Resident 97's admission Record (AR), the AR indicated Resident 97 was admitted on [DATE] with multiple diagnoses which included frontotemporal neurocognitive disorder (group of rare brain disorder leading to changes in personality and behavior, problems with language or difficulty with movement), dementia with psychotic disturbances (a progressive state of decline in mental abilities) and type 2 diabetes mellitus (DM-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 40 sampled residents (Resident 14) was offered activities that met their interests and preferences.This failure had the potential to affect the resident's physical, mental, and psychosocial well-being.During a review of Resident 14's admission Record (AR), the AR indicated Resident 14 was admitted on [DATE] with multiple diagnoses which included dementia (a progressive state of decline in mental abilities).During an observation on [DATE] at 11:25 a.m., 1:20 p.m., and 2:45 p.m. respectively, Resident 14 was in her room, sitting up on the bed with no activity.During an observation on [DATE] at 8:55 a.m., 11:22 a.m., and 1:23 p.m. respectively, Resident 14 was in her room, sitting up on the bed with no activity.During a review of Resident 14's Activity Progress Note (APN), dated [DATE], the APN indicated, Resident 14's activity preference included independently reading books, newspapers, and magazines and listening to music in…

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

Based on observation, interview, and record review, the facility failed to prevent one of forty sampled residents (Resident 157) from developing a facility acquired pressure injury (injury to the skin and underlying tissue due to prolonged pressure).This failure resulted in Resident 157 developing pressure injuries to right and left heels causing decreased mobility and increased risk for infection. A review of Resident 157's admission Record indicated Resident 157 was admitted to the facility June 2025 with multiple diagnoses including Alzheimer's disease (a progressive disease that destroys memory and other mental functions), obstructive sleep apnea (intermittent airflow blockage during sleep) and chronic kidney disease (loss of kidney function that filters waste from the body). A review of Resident 157's Minimum Data Set (MDS- federally mandated assessment tool), Cognitive Patterns, dated 7/2/25, indicated Resident 157 had a Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 0 out of 15 that indicated Resident 157 had severe cognitive impairment. A review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 40 sampled residents' (Resident 9) weight was not maintained when Registered Dietician's (RD) recommendation for therapeutic diet was not followed.This failure resulted in Resident 9's significant weight loss and had the potential to place the resident at risk for further weight loss.Findings:During a review of Resident 9's admission Record (AR), the AR indicated Resident 9 was admitted on [DATE] with multiple diagnoses which included type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), dementia (a progressive state of decline in mental abilities), gastro-esophageal reflux disease (GERD-digestive condition where stomach acid flows back up causing discomfort.)During a review of Resident 9's Nutritional Risk Assessment (NRA), dated 6/2/25, the NRA indicated Resident 9 had lost 9.9% or 20.6 pounds (lbs.-unit of measurement) in three months. Resident 9's NRA indicated, Resident 9…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 adequate pain management was provided, consistent with professional standards of practice for one of 40 sampled residents (Resident 46), when the pain medication was not administered, administered later than the scheduled time, ongoing pain assessments every shift were not completed accurately, and the resident was not monitored for side-effects of pain medication. These failures resulted in Resident 46 experiencing uncontrolled pain and suffering, affected resident's simple movements causing frustration, and had the potential to increase his feeling of depression. Findings:A review of the admission Record indicated the facility admitted Resident 46 in 2022 with multiple diagnoses, which included left leg below knee amputation (BKA), chronic pain syndrome, and phantom limb syndrome with pain (a condition when the individual experience persistent pain, sensations, or movement in a limb that has been amputated or lost).A review of Resident 46's Minimum Data Set (MDS, a federally mandated 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.

Based on observation, interview, and record review, the facility failed to ensure Licensed Nurse (LN) 17 had the specific skill sets and competencies necessary to care for residents' needs when LN 17 did not have a competency evaluation done before providing care to residents. This failure resulted in Resident 37 and Resident 46 receiving their medications late, which caused pain and discomfort. During a review of Resident 37's admission record, the admission record indicated, Resident 37 was admitted to the facility July 2023 with multiple diagnoses which included Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements).During a review of Resident 37's active orders dated 8/15/25, the orders indicated .Carbidopa -Levodopa (Combination medication used to treat the symptoms of Parkinson's disease. It helps manage motor symptoms such as stiffness, tremors, and difficulty with movement) .Give 2 tablet by mouth every 4 hours for Parkinson's Disease.During a concurrent observation and interview on 9/16/25 at 1:15…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 40 sampled residents (Resident 64 and Resident 3) were free from unnecessary psychotropic medications (medications intended to control behavioral symptoms, including mind, emotions, and behavior) use, when:Resident 64 was prescribed Fluoxetine (an antidepressant medication) without specific manifested behavior of depression, and without monitoring for adverse effects (unwanted, uncomfortable, or dangerous effects). In addition, the facility failed to obtain an informed consent (voluntary agreement to accept treatment after receiving education regarding the risks and benefits, and alternatives ordered) before starting the antidepressant medication.Resident 3's diagnoses did not include depression for the anti-depression medication, and medication change ordered by the behavioral health provider was not implemented. Additionally, the reason for denial of the order was not documented in the medical record.These failures placed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 1 resident in a census of 162 (Resident 46) was free from significant medication error when: 1) Licensed Nurse (LN) administered resident's pain medication late and not in accordance with the physician's orders and;2) LN did not administer blood pressure medicationThese failures decreased the facility's potential to ensure residents are able attain or maintain their highest practicable physical, mental, and psychosocial well-being.Findings:During a review of Resident 46's admission Record, Resident 46 was admitted to the facility in March 2011 with diagnoses which included acquired absence of left leg below knee, hypertension (HTN-high blood pressure), and chronic pain syndrome. Resident 46's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 9/11/25, indicated, Resident 124 had intact cognition. During an observation of medication administration on 9/18/25 at 10:40 a.m., Licensed Nurse 4 (LN 4) was observed to administer Resident 46's oral pain medication,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a bed control remote (a handheld device that is connected by a cable to a bed and allows a person to adjust the position of a bed, elevate the head or feet) in a safe operating condition for one of 40 sampled residents (Resident 140), when the insulation (a protective barrier) around the electrical cord was broken exposing wires. This failure had the potential to result in serious risks to Resident 140's safety.Findings: A review of the admission record indicated that facility admitted Resident140 earlier this year with multiple diagnoses, including stroke, dementia (a progressive state of decline in mental abilities), and muscle weakness. During an observation on 9/16/25 at 12 p.m., Resident 140 was observed sitting on the edge of the bed. Resident 140 was alert and able to carry a small conversation. During further observation, Resident 140 grabbed the bed control remote from the floor and pointed to it. The part of the cord closer to the remote was observed to be ripped with wires exposed. Observed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 call lights were accessible for two of forty sampled residents (Resident 138, Resident 10) when:1.Resident 138's call light was shut in the nightstand drawer, and2.Resident 10's call light was on the floor behind the nightstand.These failures had the potential for Resident 138 and Resident 10 to have unmet care needs leading to increased risk for falls and injuries. Findings:1.A review of Resident 138's admission Record, indicated Resident 138 was admitted to the facility May 2025 with multiple diagnoses including fracture of left wrist, fracture of right hand metacarpal (bones of the hand that connect wrist to the fingers), diabetes (too much sugar in the blood), cognitive impairment (memory and thinking problems), and generalized muscle weakness. A review of Resident 138's Minimum Data Set (MDS- federally mandated assessment tool), Cognitive Patterns, dated 8/12/25, indicated Resident 138 had a Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 8 out of 15 that indicated…

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

Based on interviews and record reviews, the facility failed to notify one resident (Resident 1) of two sampled residents about a significant medication error that occurred when licensed nurses administered a double-dose of insulin lispro (a fast-acting, man-made insulin (a hormone that regulates blood sugar allowing it to be used by our body as energy) used to treat diabetes) on the morning of 8/19/25 and caused Resident 1 to experience a potentially life-threatening hypoglycemic (a low blood sugar level that can cause harm; a level below 54 milligram per deciliter (mg/dl) is a cause for immediate action) episode, when her blood sugar level went down to 43 mg/dl.This failure denied Resident 1 her right to consent to subsequent treatments and to make informed decisions about her own plan of care.Findings:A review of Resident 1's admission record indicated admission to the facility on 1/7/25 with a diagnosis of Type 1 diabetes (a chronic condition in which the pancreas makes little or no insulin (a hormone the body uses to use sugar (glucose) to produce energy). This record also…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reviews, the facility failed to assist one resident (Resident 2) of two sampled residents, to obtain dental care to be conducted in a timely manner, after the facility received a letter from a local oral surgery clinic which indicated Resident 2 had to be referred to a hospital to receive the procedure he needed.This failure decreased the facility's potential to ensure residents received the necessary care and increased Resident 1's potential to experience oral pain and discomfort which could negatively affect his health and well-being. Findings:A review of Resident 2's admission record indicated admission to the facility on [DATE] with diagnosis which included heart failure (a chronic condition in which the heart is unable to pump blood as well as it should) and chronic kidney disease (a condition where the kidneys are unable to filter waste from the blood).A review of Resident 2's care plan initiated on 1/27/24 indicted, The resident has oral/dental problems r/t [related to] poor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prevent one of six sampled residents (Resident 2) from being assaulted when Resident 1 hit Resident 2 on the back of her head.This failure resulted in Resident 2 feeling distressed and had the potential to result in Resident 2 experiencing feelings of fear and anxiety.A review of Resident 1's admission Record (AR), indicated the facility admitted Resident 1 on 6/19/25 with medical diagnoses which included end stage renal disease (a condition where the kidneys have permanently lost most of their function and can no longer adequately filter waste products and excess fluid from the blood) and vascular dementia (a type of cognitive decline caused by damage to the blood vessels in the brain).A review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 5/14/25, indicated Resident1's cognitive (the ability to think and process information) skills for daily decision making were intact.A review of Resident 2's AR indicated the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of six sampled residents (Resident 3) received a federally required PASSR (Preadmission Screening and Resident Review - a federal requirement ensuring individuals with serious mental illness, intellectual disabilities, or related conditions are not inappropriately placed in Medicaid-certified nursing facilities and receive appropriate services) evaluation.This failure excluded Resident 3 from a complete mental health evaluation for appropriate facility placement, and non-receipt of available mental-health resources from the California Department of Developmental Services (DDS).A review of Resident 3's, admission Record (AR), indicated Resident 3 was originally admitted to the facility on [DATE], with medical diagnoses which included metabolic encephalopathy (the brain does not function properly due to underlying metabolic disturbances) cognitive communication deficit (difficulty with communication skills that results from impaired thinking…

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

Based on interview and record review, the facility failed to ensure an allegation of abuse was reported within the required timeframe for two of two sampled residents (Resident 1 and Resident 2) when no documentation was received by the Department of Public Health (the Department) until four days after the alleged abuse occurred.This failure of timely reporting had the potential to cause a delayed response by enforcement agencies to ensure resident safety.Findings:A review of a facility document titled Investigation Summary of Resident 1 and Resident 2 dated 7/17/25 and received by the Department on 7/17/25, indicated Resident 1 made verbal threats towards Resident 2 on 7/13/25.During an interview on 8/19/25 at 12:12 p.m., the Administrator (ADM) stated it was the facility's policy to report an allegation of abuse to the Department within two hours. The ADM confirmed the facility sent the five-day follow up report to the Department on 7/17/25 for an incident of alleged abuse on 7/13/25.During an interview on 8/19/25 at 12:30 p.m., Licensed Nurse A (LN A) stated he faxed a State of…

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

Based on interview and record review the facility failed to ensure one out of three sampled residents (Resident 1), was free from a significant medication error (an error in administering prescribed medication, which causes the resident discomfort or jeopardizes their health and safety), when the facility did not acquire nor administer Resident 1's antibiotic (a medicine that fights infection) per physician's orders.This failure could result in worsening of Resident 1's medical condition. Findings:A review of Resident 1's hospital discharge form, printed 7/12/25, indicated Resident 1 had a complicated medical history and had been admitted to the hospital with a spinal infection and abscess (a localized collection of pus surrounded by inflamed tissue) which was being treated for lumbosacral-spine-osteomyelitis, (a bone infection of the lower part of the spine).In a concurrent interview and record review on 8/1/25 at 8:57 a.m. with the Director of Business Development (DBD), Resident 1's admission communications were reviewed. The DBD stated she was involved in the admitting process…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medical records were accurately documented for one out of three sampled residents (Resident 1), when Resident 1's medication administration record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) indicated, inaccurately, that Resident 1 was not administered a prescribed medication due to being in the hospital. This failure caused Resident 1's medical records to be inaccurate.Findings:A record review of Resident 1's SNF [Skilled Nursing Facility]/NF [Nursing Facility] to Hospital Transfer Form, dated 7/13/25, indicated Resident 1 was admitted to the facility on [DATE] and discharged from the facility to the hospital on 7/13/25 at 7:15 p.m.In a concurrent interview and record review on 8/8/25 at 1:30 p.m., with the Director of Nursing (DON), Resident 1's MAR, dated July 2025, Resident 1's SNF/NF to Hospital Transfer Form, dated 7/13/25, and facility policy titled,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 implement and maintain their compliance and ethics program when the facility produced false evidence of nursing registry staff (licensed or certified nursing staff paid by a third party to work at a nursing facility) orientation.This failure contributed to the neglect of providing orientation and training to staff prior to working independently and placed the residents in the facility at risk of receiving unsafe care.On 5/19/25 the California Department of Public Health (CDPH) issued the facility a violation of federal regulations regarding the lack of effective training among nursing registry staff prior to independently providing services to residents.A review of the facility's Plan of Correction (POC- a document which outlined how a facility will address and correct identified deficiencies identified during an inspection) submitted to the CDPH by the facility on 6/20/25 indicated, .On 6/20/25, in-services [training] were provided by DON [Director of Nursing] to unit managers, DSD [Director of Staff Development], 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, observation and record review, the facility failed to provide necessary services to maintain grooming and hygiene for two of nine sampled residents (Resident 1 and Resident 2).This failure resulted in both residents experiencing pain and anxiety and had the potential for skin breakdown and worsening of medical conditions.1.During a review of Resident 1's admission Record (Face Sheet), printed 7/8/25, it indicated the facility admitted Resident 1 on 1/27/18 with diagnoses including hemiplegia and hemiparesis (both involve weakness on one side of the body, but hemiplegia refers to complete paralysis, while hemiparesis refers to partial weakness) affecting the left side, major depressive disorder (a serious mental illness characterized by persistent sadness, loss of interest in activities, and other symptoms that significantly interfere with daily life), and cognitive social /emotional deficit (impairments in thinking, social interaction, or emotional processing) following cerebrovascular accident (a medical emergency where blood flow to the brain is interrupted,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 nine sampled residents (Resident 1 and Resident 2) received treatment when the facility did not perform necessary incontinent (having no or insufficient voluntary control over urination or defecation) care and hygiene.This failure had the resulted in both Residents experiencing pain and discomfort, and the potential for new development or worsening of medical conditions.1.During a review of Resident 1's admission Record (Face Sheet), it indicated the facility admitted Resident 1 on 1/27/18 with diagnoses including hemiplegia and hemiparesis (both involve weakness on one side of the body, but hemiplegia refers to complete paralysis, while hemiparesis refers to partial weakness) affecting the left side, major depressive disorder (a serious mental illness characterized by persistent sadness, loss of interest in activities, and other symptoms that significantly interfere with daily life), and cognitive social /emotional deficit…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the necessary services for two of nine sampled residents (Resident 1 and Resident 2) when call lights were not operational, not adaptively placed for a disabled resident, and were not answered for a period of two hours.This failure resulted in both residents experiencing pain, discomfort, and anxiety secondary to delayed incontinence (involuntary leakage of urine or stool) care.1.During a review of Resident 1's admission Record (Face Sheet), printed 7/8/25, it indicated the facility admitted Resident 1 on 1/27/18 with diagnoses including hemiplegia and hemiparesis (both involve weakness on one side of the body, but hemiplegia refers to complete paralysis, while hemiparesis refers to partial weakness) affecting the left side, major depressive disorder (a serious mental illness characterized by persistent sadness, loss of interest in activities, and other symptoms that significantly interfere with daily life), and cognitive social…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews and record reviews, the facility failed to ensure accurate and complete resident medical records for four residents (Resident 1, Resident 2, Resident 3, and Resident 4) of four sampled residents when administration of medications during the evening shift of 6/18/25 was missing on their Electronic Medication Administration Record (EMAR). This failure decreased the facility's potential to ensure accurate documentation of resident care provided and increased the potential of medication errors. Findings: On 7/2/25 at 2:50 p.m., a review of Resident 1, Resident 2, Resident 3, and Resident 4's EMARs dated 6/18/25 indicated Licensed Nurse A (LN A) did not document the administration of the following medications: -Resident 1's 5 p.m. dose of levetiracetam (medication used to prevent seizures) oral solution 500 milligram (mg)/ 5 milliliters (ml) for seizure disorder; 9 p.m. dose of atorvastatin (medication used to treat high cholesterol) 40 mg tablet at bedtime for hyperlipidemia (high cholesterol); and 9 p.m. senna (medication used to treat constipation) tablet 8.6 mg…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 sufficient nursing staff for seven residents (Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, and Resident 8) of eight sampled residents when residents ' medications were not administered when scheduled. This failure decreased the facility ' s potential to safely meet the residents ' needs in a manner that promotes their physical well-being. Cross reference F760 and F940. Findings: A review of Resident 2 ' s admission record indicated admission to the facility in January 2025 with a diagnosis which included diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing). A review of a Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 4/9/25, indicated Resident 2 had moderate cognitive (relating to the mental process involved in knowing, learning, and understanding things) impairment. A review of Resident 2 ' s Medication Administration…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 six residents (Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, and Resident 7) of seven sampled residents, were free from significant medication errors when the following medications were not administered in accordance with the physician ' s order: 1. Resident 2 ' s insulin lispro (a rapid-acting medication used to treat Diabetes Mellitus (DM -a disorder characterized by difficulty in blood sugar control and poor wound healing)) and insulin glargine (a long acting, steady release medication used to treat DM) were administered late; 2. Resident 2 was administered the wrong dose of nutritional insulin (insulin lispro); 3.Resident 3 ' s Admelog® (a rapid-acting medication used to treat DM) and Basaglar® (a long acting, steady release medication used to treat DM) were administered late and one dose of Admelog® was not administered; 4. Resident 4 ' s insulin lispro and Humulin (an intermediate acting (works for about half 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 registry staff (nurses who work on a contracted as needed or temporary basis via contractual arrangement) were effectively trained prior to independently providing services to residents for a census of 174 residents. This failure decreased the facility ' s potential to provide person-centered care and reduce the potential of adverse events. Cross reference F725 and F760. Findings: A review of Resident 4 ' s admission record indicated admission to the facility in July 2021 with a diagnosis which included DM with moderate bilateral (affects both eyes) non-proliferative diabetic retinopathy without macular edema (damage to the blood vessels of the retina (a light-sensitive layer of tissue lining the back of the eye) but the macula (part of the retina responsible for central vision) is not affected by swelling or fluid buildup as a result of DM). A review of Resident 4 ' s MDS dated [DATE] indicated Resident 4 had no cognitive impairment. A review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 initiate and update person-centered care plans for two residents (Resident 4 and Resident 5) of eight sampled residents when Resident 4 and Resident 5 ' s care plans did not indicate preferences of their needs. This failure decreased the facility ' s potential to provide consistently communicated personalized care to residents. Cross reference F940. Findings: 1. A review of Resident 4 ' s admission record indicated admission to the facility in July 2021 with a diagnosis which included diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) with moderate bilateral (affects both eyes) non-proliferative diabetic retinopathy without macular edema (damage to the blood vessels of the retina (a light-sensitive layer of tissue lining the back of the eye) but the macula (part of the retina responsible for central vision) is not affected by swelling or fluid buildup as a result of DM) and legal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews and record reviews, the facility failed to establish and implement an appropriate abuse policy and procedure (P&P) when: 1. the facility's P&P titled Reporting Abuse was not revised to reflect current reporting guidelines, and 2. staff were not able to correctly state whom to report or the time frames to report abuse allegations. These failures could put all 174 residents of the facility at risk for abuse without timely interventions. Findings: 1. A review of the facility's P&P titled Reporting Abuse , revised 1/8/2014, indicated, .If the reportable incident results in serious bodily injury, a telephone report shall be made to the local law enforcement agency immediately and no later than 2 hours of the observation, knowledge or suspicion of the physical abuse. In addition, a written report shall be made to the local ombudsman, the California Department of Public Health and the local law enforcement agency within 2 hours of the observation, knowledge or suspicion of the physical abuse .If the reportable incident does not result in serious bodily injury, 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 interviews and record reviews, the facility failed to ensure five out of five sampled residents (Resident 7, 8, 9 10 and 11) baseline care plans (BCP, a document created within 48 hours of a resident's admission to a nursing home, outlining the initial care needed to ensure residents' safety and well-being, focusing on basic needs and resident-specific information) was completed within 48 hours of admission or that a copy of the BCP was given to those residents or the resident representatives. These failures could compromise the residents' care and could have resulted in health complications. Findings: A review of Resident 7's BCP-V2 form indicated an admission date of 5/4/25 and completed by the Dietary Manager (DM) on 5/9/25. The signature of the resident and the resident representative was left blank. A review of Resident 8's BCP-V2 form indicated an admission date of 5/3/25 and completed by the Director of Rehabilitation (DOR) services on 5/8/25. The signature of the resident and the resident representative was left blank. A review of Resident 9's BCP-V2 form indicated…

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

Based on observation, interview and record review, the facility failed to ensure their smoking policy was implemented in a safe manner and was operationalized as per the set regulations regarding smoking, and protection for four out of four sampled smoking residents when: 1. Resident 3 was not wearing a smoking blanket/apron (protective covering, typically made from flame-retardant fabric, used to shield smokers from burns and protect their clothing from hot ashes and cigarettes) while smoking, 2. Resident 4 was not supervised by staff while smoking, 3. Resident 6 kept his own cigarettes, and 4. Residents were not following the facility's smoking schedule. These failures had the potential to endanger the health and safety of smoking residents. Findings: 1. A review of Resident 3's face sheet (front page of the chart that contains a summary of basic information about the resident) indicated Resident 3 was admitted to the facility in September 2022 with diagnoses which included nicotine dependence (ND, a state of substance dependence on nicotine), lack of coordination, and muscle…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews and reviews, the facility failed to notify the physician of a significant change for one out of two sampled residents (Resident 12), when Resident 12's unintentional weight loss was not reported to the physician. This failure could result in missed opportunity to provide timely intervention. Findings: A review of Resident 12's face sheet (front page of the chart that contains a summary of basic information about the resident) indicated Resident 12 was admitted to the facility in July 2019 with diagnoses including dementia (a progressive state of decline in mental abilities) and dysphagia (difficulty swallowing). A review of Resident 12's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 4/10/25, indicated Resident 12 was dependent on staff for feeding assistance. The MDS also indicated Resident 12 had lost weight but was not on a physician prescribed weight loss regimen. A review of Resident 12's Weights and Vitals Summary indicated Resident 12 weighed 97.3 pounds (lbs. a unit of weight) on 4/4/25 and 92.1 lbs. on 5/6/25. Resident 12…

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

Based on observation, interviews and record reviews, the facility failed to ensure one resident out of two sampled residents (Resident 12) who was dependent on staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) received services to maintain grooming and personal hygiene when Resident 12 was not provided showers as scheduled. This failure could result in discomfort, skin impairment and body odor. Findings: A review of Resident 12's face sheet (front page of the chart that contains a summary of basic information about the resident) indicated Resident 12 was admitted to the facility in July 2019 with diagnoses including dementia (a progressive state of decline in mental abilities) and dysphagia (difficulty swallowing). A review of Resident 12s Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 4/10/25, indicated Resident 12 was dependent on staff for provision showers/baths and personal hygiene. During an observation on 5/14/25 at 11:17 a.m., Resident 12…

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

Based on observation, interviews and record reviews, the facility failed to ensure the dignity of one out of three sampled residents (Resident 2) was protected when Licensed Nurse C (LN C) teasingly pinched Resident 2 on numerous occasions despite Resident 2 requesting multiple times for LN C to refrain from doing so. This failure resulted in Resident 2 feeling disrespected, frustrated, and her dignity was violated. Findings During a concurrent observation and interview on 5/1/25 at 11:12 a.m., Resident 2 stated LN C, a nurse who cared for her, had a habit of pinching her. Resident 2 stated LN C liked to pinch residents and added, LN C also pinched Resident 4. Resident 2 stated LN C would pinch her on her arms and added, she knew the difference between being pinched as necessary when being given an injection versus being pinched when LN C was teasing her. Resident 2 stated LN C would pinch her even when LN C was not administering her an injection. Resident 2 stated she understood that LN C was playful but stated she did not like being pinched. Resident 2 stated she told him multiple…

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

Based on observation, interviews and record reviews, the facility failed to report the result of an investigation for an injury of unknown source (an injury where the source is not observed by anyone and the resident cannot explain how it occurred, and the injury is suspicious due to its location, extent, or the number of injuries) for one out of three sampled residents (Resident 1) when no report was received by the California Department of Public Health (the Department) within five working days of the incident. This failure of timely reporting had the potential to cause a delayed response by enforcement agencies to ensure resident safety. Findings: A review of Resident 1 ' s face sheet (front page of the chart that contains a summary of basic information about the resident) indicated Resident 1 was admitted to the facility in April of 2025 with a diagnosis of contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) of right and left hand. A review of Resident 1 ' s SBAR (situation, background, assessment, recommendation-a communication tool used…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure rehabilitative services were adequately provided for one resident (Resident 1) of three sampled residents when the rehabilitation staff (professionals who work together to help patients regain their functional abilities after illness, injury, or disability) did not carry out a physician order to evaluate Resident 1 for Physical Therapy (PT-A therapy that helps improve how the body performs physical movements), Occupational Therapy (OT- A therapy that encourages rehabilitation through the performance of activities required in daily life) and Speech Therapy (ST-A therapy that improves the ability to talk and swallow) services within 24 to 72 hours. As a result, these services were not provided to Resident 1 for several months. This failure decreased the facility's potential to assist Resident 1 to attain and maintain his highest practicable level of functional well-being. Findings: A review of Resident 1's admission record indicated he 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 interview and record, the facility failed to maintain the dignity of two of four sampled residents (Resident 3 and Resident 6) when Resident's 3 cheek was pinched without her consent and Resident 6 was continually not called by her preferred name pronunciation. This failure left Resident 3 and Resident 6 feeling angry and disrespected. Findings: During an interview 3/5/25 at 3:38 p.m., Resident 3 stated Licensed Staff A had used the index finger and thumb to pinch her cheek. Resident 3 stated it was not gentle it was rough, and she was angry because she did not like it when he did that to her. Resident 3 stated she did not want Licensed Staff A to take care of her any longer, as she went to college to be a dental hygienist and knew how to treat patients and added, Licensed Staff A did not know how to treat patients. During an interview on 3/5/25 at 2:11 p.m. with the Director of Nursing (DON), the DON stated Licensed Staff A was disciplined (a notice was place in personnel file) regarding pinching a resident on the cheek. DON stated she would prefer that staff not pinch…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Licensed Nurses (LNs) administered medication to five residents (Resident 1, Resident 2, Resident 3, Resident 4, and Resident 5) of five sampled residents during a facility power outage which occurred on 12/14/25 to 12/15/25 when there was no documented evidence resident medications were administered. This failure resulted in residents who did not receive their medications and decreased the facility ' s potential to ensure residents received necessary medications during a power outage. Findings: A review of Resident 1 ' s admission record indicated admission to the facility in March 2020 with diagnoses which included dementia (a progressive state of decline in mental abilities), hypertension (high blood pressure), major depressive disorder (mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities), and insomnia (trouble falling asleep or staying asleep). 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.

Based on interview and record review, the facility failed to ensure a contingency plan was in place and was included in the facility assessment for the administration of resident medication when the facility experienced a power outage on 12/14/24- 12/15/24. This failure resulted in five residents (Resident 1, Resident 2, Resident 3, Resident 4, and Resident 5) out of five sampled residents having no documented evidence their medications were administered and decreased the facility ' s potential to ensure residents received necessary care during a power outage. This was cross-referenced and cited at F658. Findings: In an interview on 2/13/25 at 1:03 p.m., the Plant Operations Manager (POM) confirmed the facility experienced a power outage on 12/14/24 due to bad storms in the area. The POM stated the facility ' s generator kicked in and he implemented the facility ' s emergency back-up plan. Extension cords were plugged into emergency outlets to provide power to beds, emergency lighting was used, and all fire doors were checked for electrical and were functioning. The POM stated 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 interview, and record review the facility failed to ensure one resident (Resident 1), was free from verbal abuse when Physician A asked Resident 1, Aren't you a shit? This failure resulted in Resident 1 feeling upset and angry from being verbally abused. Findings: Review of Resident 1's medical record indicated admission to the facility on 3/20/23 with a medical history that included diagnoses of Insomnia ((trouble falling asleep or staying asleep) and borderline personality disorder (a complex and chronic mental health condition characterized by intense and unstable emotions, impulsive behaviors, and difficulty maintaining relationship). Review of Resident 1's Minimum Data Set (MDS, a resident assessment tool used to identify resident care needs) dated 12/13/24, indicated a Brief Interview for Mental Status (BIMS, an assessment of cognitive status) score of 14 of 15 which indicated no cognitive impairment. Resident 1 was his own responsible party. During an interview on 1/7/25 at 3:15 p.m., Licensed Staff B stated she and Physician A entered Resident 1's room to assess 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 report an allegation of verbal abuse in accordance with State law and established facility policies and procedures for one resident (Resident 1). This failure prevented the California Department of Public Health (CDPH, to be referred to the Department from here on) from investigating an allegation of abuse and continued to place Resident 1 and other residents at risk for abuse. Findings: Review of Resident 1's medical record indicated admission to the facility on 3/20/23 with a medical history that included diagnoses of Insomnia ((trouble falling asleep or staying asleep) and borderline personality disorder (a complex and chronic mental health condition characterized by intense and unstable emotions, impulsive behaviors, and difficulty maintaining relationship). A review of Resident 1's Minimum Data Set (MDS, a resident assessment tool used to identify resident care needs) assessment dated [DATE], indicated a Brief Interview for Mental 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.

Based on interview, and record review, the facility failed to investigate an allegation of abuse following facility policy and procedures and State requirements for one resident (Resident 1). This failure decreased the facility's potential to prevent further alleged abuse from continuing and to take appropriate corrective action. Findings: During an interview on 1/7/25 at 4:29 p.m., the Director of Nursing (DON) confirmed an allegation of verbal abuse between Resident 1 and Physician A was reported to her by Licensed Staff B on 10/25/24. The DON verified an investigation of the allegation was not conducted. During an interview on 1/9/25 at 1 p.m., the Administrator verified he was the facility's Abuse Coordinator and confirmed an allegation of verbal abuse between Resident 1 and Physician A was reported to him on 10/25/24. The Administrator stated an investigation of the abuse was not conducted or reported to any regulatory agencies. Review of the facility's policy and procedure titled, Abuse-Reporting & Investigations, revised March 2018, indicated, .Immediate Action .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 one of three sampled residents (Resident 1) was discharged safely from the facility, when: 1. Resident 1, who was insulin-dependent (Dependent on injectable insulin, a hormone that helps blood sugar enter cells to be used for energy), was discharged from the facility without a glucometer (A small, portable machine that is used to measure how much glucose (a type of sugar) is in the blood), or information on purchasing a home-use glucometer. As a result, Resident 1 refused to administer his insulin for several days, since he could not check his blood sugar levels. 2. Resident 1 was discharged to a Board and Care home (A small, private residential facility that provides housing and personal care for a small group of seniors) which was not licensed by the California Department of Social Services (DCSS- One of 16 departments and offices in the California Health and Human Services Agency whose mission is to serve, aid, and protect needy 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 become aware one of three sampled residents (Resident 1) had not received his early-morning Physician-prescribed insulin (An injected hormone that is essential for allowing the body to use sugar (glucose) for energy) most days of every month, for more than a year, until Resident 1 noticed this issue himself and reported it to Administration. As a result, Administration did not intervene until notified by Resident 1, which allowed daily significant medication administration errors to occur for Resident 1 for a period of one year, with a few exceptions. This finding had the potential to result in serious consequences for Resident 1, including uncontrolled blood glucose levels and death. Findings: Record review of the facility Face Sheet (Facility Demographic) indicated Resident 1 was admitted to the facility on [DATE], with medical diagnoses including Type 2 Diabetes Mellitus (A chronic condition that causes high blood sugar levels due to a lack 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 observations, interviews and record reviews, the facility failed to implement the interventions to reduce the risk of elopement (leaving the facility without knowledge of the staff) for one out of one sampled resident (Resident 1), who left the facility, undetected, and was found by the local Police Department. This failure had the potential to result in serious injuries, including bruises, lacerations, head injury and broken bones. Findings: During on observation on 7/17/24 at 4 p.m., Resident 1 was sitting in a chair in the hall outside of his room with the Staff person who was monitoring him. Resident 1 asked if he could go home and wanted to know when. Resident 1 had a wander guard bracelet on his right wrist. During a review of the medical records on 7/17/24, Resident 1's Elopement Evaluation, dated 6/28/24, was done on the day of his admission and had a score of six, when a score greater than one indicated a risk for elopement The evaluation section of what to do to prevent elopement was left…

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

Based on observation, interviews, and policy review, the facility failed to ensure concentration of sanitizer in the dish machine was at the correct concentration level. This deficient practice affected all residents who received food from the kitchen. Findings included: A review of the facility policy titled, Dish Machine Operation and Cleaning, with a revision date of 10/01/2014, revealed, B. Routinely monitor soap, sanitizer and rise [sic] agent to ensure adequate supply throughout operation of the dish machine. An initial tour of the kitchen was conducted with the Registered Dietitian (RD) on 01/08/2024 at 10:15 AM. Upon inspection of the dish machine, the RD conducted a test of the rinse solution using a chlorine test strip. The test strip turned a light purple color, which indicated the level of chlorine was 10 parts per million (PPM). A second test was performed at 10:30 AM by the RD with a second rinse cycle. The test strip remained a light purple color. The RD obtained a new set of test strips at 10:42 AM and conducted a third test, which measured 25 PPM. In 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 interviews, record reviews, and facility policy review, the facility failed to ensure the resident's code status was accurately documented for 1 (Resident #169) of 34 sampled residents. Findings included: Review of a facility policy titled, Physician Orders for Life-Sustaining Treatment (POLST), with a revision date of [DATE], revealed, VII. Whenever possible, ensure that the Advance Directive and the POLST form are consistent. Review of Resident #169's admission Record revealed the facility admitted the resident on [DATE] with diagnoses that included delusional disorders, adult failure to thrive, and cognitive communication deficit. Review of Resident #169's Order Review History Report, for the timeframe from [DATE] to [DATE], revealed an order dated [DATE] for cardiopulmonary resuscitation (CPR). Review of Resident #169's Physician Orders for Life-Sustaining Treatment (POLST), signed by Resident #169's responsible party (RP) and dated [DATE], revealed if the resident had no pulse and was not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interviews, record reviews, and policy review, the facility failed to ensure privacy of protected health information for 2 (Resident #32 and Resident #141) of 34 sampled residents. Specifically, instructions for care were posted in sight of roommates, visitors, and others who might not be authorized to view this information. Findings included: A review of the facility policy titled, Resident Rights, with a revision date of 01/01/2012, revealed, Employees are to treat all residents with kindness, respect, and dignity and honor the exercise of resident's rights. The policy indicated, These rights include, but are not limited to, a resident's right to: D. Privacy and confidentiality. 1. A review of Resident #32's admission Record revealed the facility admitted the resident on 03/08/2017 with diagnoses that included Alzheimer's disease, dementia, and dysphagia, A review of Resident #32's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/10/2023, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 7, which…

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

Based on observation, interviews, record review, and policy review, the facility failed to develop and implement a care plan for 1 (Resident #141) of 1 sampled resident reviewed for communication. Specifically, a care plan for communication was not developed for Resident #141, who spoke a language other than English. Findings included: Review of a facility polity titled, Person Centered Care Plan, with a revision date of November 2018, revealed, It is the policy of this Facility to provide person-centered, comprehensive, and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents in order to obtain or maintain the highest physical, mental and psychosocial well-being. Review of Resident #141's admission Record revealed the facility admitted the resident on 06/07/2023 with diagnoses that included hemiplegia and hemiparesis related to cerebral infarction, dysphagia, type 2 diabetes, and epilepsy. Review of Resident #141's quarterly Minimum Data Set (MDS), with an Assessment Reference Date…

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

Based on observations, interviews, record review, and policy review, the facility failed to implement the use of alternative communication methods for 1 (Resident #141) of 1 sampled resident reviewed for communication. Specifically, the facility did not implement methods for communication with Resident #141 who spoke a language other than English. Findings included: A review of the facility policy titled, Translation or Interpretation Services, with a revision date of 12/01/2023, revealed, The Facility provides assistance to residents with limited English proficiency and/or hearing deficiency through translation and interpretation services. Review of Resident #141's admission Record revealed the facility admitted the resident on 06/07/2023 with diagnoses that included hemiplegia and hemiparesis related to cerebral infarction, dysphagia, type 2 diabetes, and epilepsy. Review of Resident #141's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/07/2023, revealed Resident #141 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated 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 observations, interviews, record review, the facility failed to ensure staff set the low air loss mattresses (a mattress designed to distribute a resident's body weight over a broad surface and help prevent skin breakdown) according to the resident's weight for 2 (Resident #35 and Resident #77) of 3 sampled residents reviewed for pressure ulcer/injury. Findings included: 1. A review of Resident #35's admission Record revealed the facility admitted the resident on 02/10/2012. Per the admission Record, the resident had a medical history to include multiple sclerosis, cognitive communication deficit, hemiplegia affecting the left nondominant side, vascular dementia, and obesity. A review of Resident #35's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) date of 10/15/2023, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. The MDS indicated the resident was at risk of developing pressure ulcers/injuries, had one Stage 3 pressure ulcer, and had moisture…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, record reviews, and facility policy review, the facility failed to provide supervision while smoking for 2 (Resident #125 and Resident #161) of 4 sample residents reviewed for accidents. Findings included: A review of the facility's policy titled, Smoking Residents, effective date of 08/18/2023, revealed, The IDT [interdisciplinary team] will develop an individualized plan of for safe storage, use of smoking materials, assistance and/or required supervision, for residents who smoke. A review of Resident #161's admission Record indicated the facility admitted the resident on 05/20/2023, with diagnoses that included hemiplegia (paralysis) and hemiparesis (weakness) following a cerebral infarction (stroke) of the right dominant side, chronic obstructive pulmonary disease, and nicotine dependence. A review of Resident #161's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/23/2023, revealed Resident #161 had a Brief Interview for Mental Status (BIMS)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reviews, the facility ensure residents received timely treatment and care, when it failed to provide a timely dental referral for a denture (a small piece of plastic or similar material, with false teeth attached, that fits inside the mouth of someone who does not have their own teeth) evaluation for one out of two sampled residents (Resident 1). This failure led to Resident 1 feeling unhappy and frustrated at how the facility was treating him. Findings: A review of Resident 1 ' s face sheet (demographics) indicated he was admitted to the facility on [DATE], and had a diagnoses of Type 2 Diabetes Mellitus (DM, a disease that occurs when your blood glucose, also called blood sugar, is too high), Hyperlipidemia (HLP, or high cholesterol, is an excess of lipids or fats in your blood) and Benign Prostatic Hypertrophy (BPH, a condition in men in which the prostate gland is enlarged and not cancerous. His Minimum Data Sheet Assessment (MDS, a federally-mandated process for clinical…

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

Based on interview and record review, the facility failed to ensure a deep tissue injury (DTI, an injury to the soft tissue under the skin due to pressure and is usually over boney prominence)for one resident (Resident 2), received care and treatment to promote healing and prevent worsening in accordance with professional standards of practice, when the facility failed to document wound care interventions in the medical record and care plan. This failure potentially worsened the resident ' s pressure ulcer and decline in the resident ' s quality of life. Findings: Resident 2 was an eighty-five-year-old admitted to the facility in early 2022, for post-surgical (relating to, or occurring in the period following surgery) orthopedic aftercare and physical rehabilitation. Upon admission, Resident 2 was assessed for multiple skin issues (e.g., surgical wounds, skin tears, pressure injuries (Pressure injuries are sores (ulcers) that happen on areas of the skin that are under pressure) and mobility issues related to lack of coordination and unsteadiness on feet. During a medical 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.

Based on observation, interview and record review, the facility did not ensure residents received care provided with dignity and respect, when residents were observed during meal service with towels wrapped around necks, meals were served on meal trays, Certified Nursing Assistants (CNA's) assisted dependent residents with meals while standing next to them, and in an environment that had chipped paint, rust and unsightly views of commodes. These failures had the potential to decrease residents' appetite, increase depression and residents' sense of loss and isolation. Findings: Unit Two was a 15-room locked, memory unit for cognitively impaired residents with diagnoses including Dementia (A group of thinking and social behaviors that interfere with daily functioning) and Alzheimer's (A progressive disease that destroys memory and other important functions). On 4/20/21, at 1:27 p.m., three Certified Nursing Assistants (CNA's) were observed standing and feeding three seated Residents in the communal area in front of Unit Two's nursing station. An observation indicated the area had no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a comfortable, sanitary, and homelike environment, when: 1. The view in the main dining room consisted of two towers of stacked commodes, old furniture, broken equipment and black tarp that was ripped and unsecured, the walls, doors and chair rails had large amounts of chipped paint, and the floor contained stains and large amounts of black scraped marks. The dining room lacked pictures or photographs, a working clock or music, no table linens or table decor, and all resident meals were presented on plastic trays during meal service. 2. Multiple rooms (206, 207, 205, 202, 223, 217) and common areas did not look homelike, lacking pictures/photos, sufficient light, a television set or music. Closets, bathrooms, floorboards, and bathroom countertops, had paint which was either not maintained or lacked paint at all, and a mirror was missing from a shared bathroom. 3. Alarm volumes and frequencies contributed to an institutional…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff adhered to facility guidelines, when they were observed by several residents and staff using their personal cell phones in resident care areas. This failure had the potential to result in neglect of resident care and feelings of frustration for the residents involved. Findings: During a Resident Council Meeting on 4/20/21 at 11:28 a.m., Resident 167 stated she had observed staff using their personal cell phones to play games in the facility during regular work hours. Resident 167 stated she notified the Director of Nursing (DON) and the Administrator but nothing was done about it. Resident 167's MDS (Minimum Data Set-An assessment tool), dated 4/02/21, indicated her BIMS (Brief Interview of Mental Status-A cognition assessment) score was 15, which indicated her cognition was intact. During the Resident Council Meeting on 4/20/21 at 11:37 a.m., Resident 173 stated staff did not wash her properly during showers, as they seemed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation interview and record review, the facility failed to develop and implement comprehensive care plans, when: 1. Resident 125, who suffered a fracture on her left foot, did not have a nursing plan of care developed or implemented, to care for the fracture and prevent it from reoccurring; 2. Review of eight resident records in the Memory Care Unit indicated: Resident 132's activity care plan was dated four years after initial admission, five residents (Sampled Resident 56, 28, 13, 66, 133) did not have activity care plans, and eight residents (Sampled Residents 132, 133, 66, 13, 28, 56, 67 and 115) did not have quarterly activity care plan review / updates, and; 3. The facility did not ensure a nursing care plan for the prevention of constipation was created and implemented, for Resident 41. These failures had the potential to result in lack of nursing and activity services for the residents involved, inability to attain and maintain their highest practicable physical, mental and psychosocial…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 dental care to one of seven sampled residents (Resident 84) on several occasions. This failure had the potential to result in tooth decay and loss of teeth, affecting nutrition, comfort and dignity for Resident 84. Findings: Resident 84 was admitted to the facility on [DATE], with medical diagnoses including Hypertension (High blood pressure) and Dementia (A group of symptoms that affects memory, thinking and interferes with daily life), according to the facility Face Sheet (Facility Demographic). Resident 84's MDS (Minimum Data Set-An assessment tool) dated 3/02/21, indicated her BIMS (Brief Interview of Mental Status-A cognition assessment) score was 99, which indicated Resident 84 was unable to complete the interview. The MDS also indicated Resident 84 required extensive assistance from one staff for personal hygiene. During an initial observation on 04/20/21 at 9:27 a.m., Resident 84 was in bed. On closer observation, it was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure all residents had access to, and participated in, activities which reflected the preferences of each resident, when: 1. Individual and Group Activities for Residents of Unit Two were not observed or documented, Resident Activity Care Plans were not assessed, initiated and revised in a timely fashion, according to facility Policy and Procedure (P&P), for eight Sampled Residents (132, 133, 13, 66, 28, 56, 67, 115), and Activity staffing was insufficient to meet the needs of the residents, in Unit Two; 2. The facility did not provide activities to two dependent Residents (Residents 84 and Resident 165) based on their needs and interests, in Unit One, and; 3. The facility did not perform an activity assessment, and develop a care plan for Resident 378. These failures created an institutional environment which did not support residents' choice of activities and potentially contributed to increased resident behaviors, anxiety 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 staff provided appropriate respiratory care for two supplemental oxygen-dependent residents, when: 1. A Licensed Staff did not ensure an oxygen tank was changed before becoming empty, for a supplemental oxygen-dependent resident (Resident 24), and; 2. The facility did not follow physicians' orders in regards to oxygen administration, for one resident (Resident 127). These failures had the potential to result in serious harm and potential death to the residents involved. Findings: 1. Resident 24 was admitted to the facility on [DATE], with medical diagnoses including Chronic Obstructive Pulmonary Disease (COPD-A chronic inflammatory lung disease that causes obstructed airflow from the lungs) with Acute Exacerbation (A sudden worsening of COPD) and Heart Failure (A condition in which the heart muscle is unable to pump enough blood to meet the body's needs), according to the facility Face Sheet (Facility demographic). Resident 24'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.

Based on observation, interview and record review, the facility failed to ensure call lights were answered in a timely manner. This failure may result in residents' unmet needs and accidents. Findings: During a concurrent observation and interview on 4/20/21, at 9:07 a.m., Resident 42 was sitting in his wheelchair, wheeling himself from the bathroom. Resident 42 stated he wanted to leave the facility for, better care. Resident 42 stated the call light was not answered in a timely manner; he needed to wait half an hour or longer. During a Resident Council Meeting on 4/20/21, at 11:06 a.m., concerns about answering call lights were discussed. Resident 141 stated staff just turned off call lights. Resident 167 stated staff turned off call lights because staff were on their cell phones. Resident 71 stated call light were answered but was told to wait after breakfast. Resident 71 stated she had an accident while waiting for bathroom assistance after breakfast. During an observation on 4/20/21, from 1:32 p.m. to 1:36 p.m., a call light alarm was noted in Nursing Station 1. The Assistant…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 did not ensure residents received services, activities and care required for them to achieve their highest practicable level of well-being, when the facility had 20 Certified Nursing Assistant (CNA) vacancies, 9 licensed nursing vacancies, 4 vacancies in the Activity Department, and 13 out of 30 housekeeping shifts went unfilled. These failures had the potential to contribute to decreased psychosocial well-being, rehabilitation services, activities, cognitive decline, and increased agitation, depression, and anxiety. Findings: During an interview, in Unit Two, on 4/21/22 at 3:10 p.m., Unlicensed Staff AAA stated she had 22 residents on her assignment. She stated there was not enough time to check residents every two hours for incontinence or repositioning. She stated there was no time to engage with residents, talk with them, or do activities with them. She stated all she did was try to make sure they did not hurt themselves or leave the unit. During an interview, on 4/21/21 at 10:15 a.m., Licensed Staff ZZ 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.

Based on observation, interview and record review, the facility failed to destroy controlled substance medications, according to facility policy. This failure resulted in the potential for unauthorized staff and residents to gain access to controlled substances. Findings: During an observation and interview on 4/22/21 at 9:09 a.m., in the DON's (Director of Nursing) office, the DON opened a filing cabinet drawer which contained a sharps' container. As the DON shook this sharps' container' she stated, See, you can hear all the pills. Three inches of undestroyed whole narcotics were in the unlocked container with intact narcotic pills on top of the lid. The DON stated, We just destroy the pills by placing them in this container. When asked if the DON destroyed the whole pills further, she stated, No. During a phone interview with Licensed Staff Y on 4/22/21 at 9:20 a.m., Licensed Staff Y was queried if he destroyed controlled substances with the Facility DON. Licensed Staff Y stated, Yes, I come to the facility to destroy the controlled substances with the DON. When asked how 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 did not properly store and monitor residents' food in the units' refrigerators designated for the residents food from home. This was a problem for four of four refrigerators. This failure had the potential of residents having a food-borne illness. Findings: During an observation on 4/22/21 at 9:45 a.m., Unit 4's refrigerator for storage of residents' food from home was checked. There was a sign on the refrigerator door directing the staff to label the food with resident name, room number and the date item was placed in the refrigerator. Food items were to be discarded after 48 hours. Inside the refrigerator and freezer where various open and closed food items labeled with a room number or no label at all. During an observation and concurrent interview on 4/22/21 at 9:50 a.m., Licensed Staff G acknowledged not all food items were labeled properly. Licensed Staff G removed two open and unlabeled drink containers from the refrigerator. During an observation on 4/22/21 at 10 a.m., Unit 3's refrigerator had a copy of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure medical records were complete and accurate for Activities of Daily Living for two of four residents (Resident 84, and Resident 26). The records had missing documentation for daily consumption of meals and fluids, among other categories. This failure had the potential to result in inability for staff to respond to the status and needs of the residents, and lack of availability of information to facilitate communication among the Interdisciplinary Team. Findings: Resident 84 Resident 84 was admitted to the facility on [DATE], with medical diagnoses including Hypertension (High blood pressure) and Dementia (A group of symptoms that affects memory, thinking and interferes with daily life), according to the facility Face Sheet (Facility Demographic). Resident 84's MDS (Minimum Data Set-An assessment tool), dated 3/02/21, indicated her BIMS (Brief Interview of Mental Status-A cognition assessment) score was 99 which indicated she was unable to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement infection prevention and control practices, when: 1. Isolation and proper Personal Protective Equipment (PPE) use were not followed in the observation unit and in the lobby; 2. Staff did not practice hand hygiene during mealtime and did not offer residents hand hygiene during mealtime; and, 3. Two dietary aides wore cloth masks inside the kitchen. These failures may result in transmission of Covid-19 infection and other communicable diseases among residents and staff in the facility. Findings: 1. During a concurrent observation and interview on 4/19/21, at 11:24 a.m., Unlicensed Staff N was entering Resident 1's room, which was a yellow zone (observation unit for new admit and re-admitted residents) without gown and gloves. Unlicensed Staff N stated, there was no need to wear a gown when entering yellow zone rooms if just giving water or something to residents; she only wore complete PPE when giving direct care to residents.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 notify the State Long Term Care Ombudsman of transfer to the hospital for one of three sampled residents (Resident 169). This failure may have resulted in Resident 169 not having an advocate for resident options and rights. Findings: During a review of Resident 169's medical records, a Notice of Transfer and Discharge Form, was not filled out but was in the closed chart. During an interview on 4/23/21, at 9:11 a.m., the Director of Nursing (DON) stated Social Services faxed the copy of the notice to the Ombudsman. The DON stated the notice form was not filled out and was not faxed to the Ombudsman. During an interview on 4/23/21, at 9:52 a.m., Unlicensed Staff D stated the nurse who was in charge of transferring residents to the hospital was the one who notified the Ombudsman. Unlicensed Staff D stated her, responsibility was about planned discharges to home and transfers to other facilities. During a review of facility's, Transfer and Discharge, policy and procedure, dated 1/20/16, indicated, B. The notification 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 adequately assess two Residents, when: 1) Resident 118 did not have a hearing deficit physical reassessment; and, 2) Resident 149 did not receive ordered oxygen. These failures resulted in Resident 118 not being able to communicate her needs effectively with those around her and Resident 149 became short of breath when his 02 (oxygen) tank was found empty. Findings: 1) During an observation on 4/20/21 at 11 a.m., Resident 118 had her call light on and was yelling, I need help for five minutes until staff came to address her needs. During a review of the (Minimum Data Set for Resident Assessment) Section C in Resident 118's medical record on 4/20/21 at 11:50 a.m., Resident 118's BIMS (Brief Mental Health Screening) was documented as 15 (indicating Resident 118 was cognitively intact). During an interview on 4/20/21 at 2:20 p.m., Resident 118 stated, They don't help me around here. Staff tell me to stop yelling but I cannot hear what they are saying. Resident 118 was queried if she had a hearing aid. 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.

Based on observation, interview and record review, the facility staff failed to identify one Resident (Resident 160) prior to medication administration. This failure had the potential to harm one resident, who could have receive the wrong medication. During an observation and interview on 4/21/21 at 10 a.m., in Resident 160's room, Licensed Staff QQ did not check Resident 160's identity prior to medication administration. When queried, regarding the facility's policy on identifying a resident prior to medication administration, Licensed Staff QQ stated, We ask their name and birth date. Resident 160 did not to have a name band on his wrist. Licensed Staff QQ did not ask Resident 160 any identifying information prior to administering his medication. During a review of the facility's policy and procedure titled, Medication Administration, revised 1/1/12, it indicated, The Licensed Nurse will verify the resident's identity before administering the medication .Medication Rights: Nursing staff will keep in mind the seven rights of medication when administering medication The right…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of two residents (Resident 24), who required supervision while smoking, received the required supervision. This failure had the potential to result in a serious fire accident to Resident 24. Findings: Resident 24 was admitted to the facility on [DATE], with medical diagnoses including Chronic Obstructive Pulmonary Disease (COPD-A chronic inflammatory lung disease that causes obstructed airflow from the lungs) with Acute Exacerbation (A sudden worsening of COPD) and Heart Failure (A condition in which the heart muscle is unable to pump enough blood to meet the body's needs), according to the facility Face Sheet (Facility demographic). Resident 24's MDS (Minimum Data Set-An assessment tool), dated 2/02/21, indicated his BIMS (Brief Interview of Mental Status-A cognition assessment) score was 12, which indicated his cognition was moderately impaired. Resident 24's physician orders for April, 2021, indicated, OXYGEN at 2l/min (Two…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 The facility failed to ensure staff provided appropriate services for the care and maintenance of a suprapubic urinary catheter (A tube that drains urine from the bladder and is inserted into the bladder through a small hole in the lower abdomen) for one of two residents (Resident 9), when: 1. Resident 9's urinary catheter bag (The bag which collects the urine and is attached to the urinary catheter) was laying on the floor while the nursing assistant attended to Resident 9, and; 2. A physician's order to change the catheter every 30 days was not carried out for more than two months. These failures had the potential to result in major urinary tract infections for Resident 9. Findings: 1. Resident 9 was admitted to the facility on [DATE], with medical diagnoses including Paraplegia (Paralysis of the legs and lower body) and Major Depressive Disorder, according to the facility Face Sheet (Facility demographic). Resident 9's MDS (Minimum Data Set-An assessment tool), dated 4/06/21, indicated his BIMS (Brief…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide rehabilitative services to one of two residents (Resident 125), per physician's orders. This failure had the potential to result in decrease in range of motion and functional mobility, lack of independence, and decline in Activities of Daily Living. Findings: Resident 125 was admitted to the facility on [DATE], with medical diagnoses including Fibromyalgia (A condition that causes pain all over the body, sleep problems, fatigue, and often emotional and mental distress) and History of Falling, according to the facility Face Sheet (Facility demographic). Resident 125's MDS (Minimum Data Set-An assessment tool), dated 3/25/21, indicated her BIMS (Brief Interview of Mental Status-A cognition assessment) score was 15, which indicated her cognition was intact. During an interview on 4/19/21 at 3:35 p.m., Resident 125 stated she had recently injured her left foot during a transfer. Resident 125 stated her foot got stuck under the chair during 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 implement a performance improvement program in QAA (Quality Assurance Administration)/QAPI (Quality Assurance & Performance Improvement-A program to maintain safety and quality of nursing homes) to address the critical staffing shortages. This failure had the potential to result in further staffing shortages, causing inability of employed facility staff to meet the residents' needs, resulting in poor quality care. Findings: During an interview on 4/19/21 at 3:35 p.m., Resident 125 stated the facility seemed to be short-staffed. Resident 125 stated, one Sunday morning it took two hours for staff to respond to call lights and another time it took an hour. Resident 125's MDS (Minimum Data Set-An assessment tool), dated 3/25/21, indicated her BIMS (Brief Interview of Mental Status-A cognition assessment) score was 15, which indicated her cognition was intact. During an interview with Unlicensed Staff PP, the Staffing Coordinator, on 4/22/21 at 9:50 a.m., he stated he worked on facility staffing creating staff work…

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