Bay Marina Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide pharmaceutical services which includes procedures that assure the accurate acquiring, receiving, dispensing, and administering of routine and emergency medications to meet the needs of three out of six sampled residents (Resident 12, 16 and 87) and to ensure controlled medication (those with high potential for abuse and addiction) were fully accounted for two out of three sampled residents (Resident 58 and 72) when: 1. Resident 12's Digoxin (medication to treat congestive heart failure [CHF, a condition where the heart muscle is weakened and cannot pump blood effectively]and heart rhythm problems), Furosemide (medication used to treat fluid build-up and swelling caused by CHF, . and treats high blood pressure) and Jardiance (medication used to help lower blood sugar levels in people with type 2 diabetes (a chronic condition where the body does not use insulin [a hormone produced by the pancreas that plays a crucial role 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure medication error rate was less than 5% when four medication errors out of 26 opportunities were observed during the medication administration for two out of five sampled residents (Resident 12 and 56). 1.Resident 12 did not receive Digoxin (medication to treat congestive heart failure (CHF, a condition where the heart muscle is weakened and cannot pump blood effectively) and heart rhythm problems), Furosemide (medication used to treat fluid build-up and swelling caused by CHF, . and treats hypertension (high blood pressure)) and Jardiance (medication used to help lower blood sugar levels in people with type 2 diabetes (a chronic condition where the body does not use insulin (a hormone produced by the pancreas that plays a crucial role in regulating blood sugar levels) effectively or does not produce enough insulin to regulate blood sugar levels) as ordered by the physician. 2. Resident 56 did not receive Vitamin D as ordered by 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, staff interview, and record review, the facility failed to store food in accordance with professional standards for safety when: 1.Unlabeled, undated food items were stored in the kitchen refrigerator. 2.A staff drink was stored in the kitchen freezer. 3. Beyond use by date food was stored in the kitchen dry storage. 4.Unlabeled, undated and beyond use by date food items were stored in the resident refrigerator. These failures had the potential for contamination of food resulting in food borne illness for 90 residents who received food from the kitchen. Findings: During an observation 3/24/25, at 10:00 a.m., the kitchen refrigerator was observed with six unlabeled and undated ready to eat puddings and the kitchen freezer was observed with a staff's energy drink. During and observation on 3/24/25, at 10:07 a.m., the kitchen dry storage was observed with a bulk container of black eye peas with a use by date of 1/3/25. During an observation on 3/24/25, at 10:35 a.m., the nurses' station resident refrigerator and freezer was observed with the following food items…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 follow proper infection control techniques and did not follow their infection control policies and procedures for two of two sampled residents, Resident 6 and Resident 35, when: 1. Nursing staff did not don gloves when handling Resident 6's soiled bed linens and personal clothing. 2. Resident 35's mattress was worn out and soiled with urine and bodily fluids. 3. Staff in the laundry room did not separate clean linens from soiled linens in the laundry room. 4. Staff in the laundry room did not change gloves after loading soiled laundry and before handling clean linens. 5. Staff in the laundry room did not clean and sanitize washing machine's exterior after loading soiled laundry. These failures resulted in Resident 35 to sleep on an unsanitary and uncomfortable worn-out mattress, not homelike, being at risk for infection, and residents being at risk for infections from cross contamination from staff causing the spread of infection among…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 allow two out of 27 Residents (Residents 45 and 70) to exercise their rights to self-determination when they were not provided nutrition in accordance with their preferences. These failures had the potential to result in Residents 45 and 70 feeling upset and disrespected. Findings: During a review of Resident 45's admission Record, printed 3/27/25, the record indicated Resident 45 was admitted to the facility in October 2021 with a diagnosis of constipation. During a review of Resident 45's Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.), dated 1/22/25, the record indicated Resident 45's BIMS score was 15. During a review of Resident 70's admission Record, printed 3/27/25, the record indicated Resident 2 was admitted to the facility in June 2023 with a diagnosis of constipation. During a…

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

Based on interview and record review, for one of six sampled residents (Resident 58) who were investigated for advance directives, the facility failed to ensure Resident 58 was afforded the right to formulate an advanced directive (a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated). This failure had the potential to result in Resident 58's wishes for life-sustaining treatment not documented and respected. Findings: During a review of Resident 58's admission Record (AR), the AR indicated, Resident 58 was admitted to the facility in January 2025 with diagnoses that included chronic obstructive pulmonary disease. The AR also indicated Resident 58 was self-responsible, and two significant others, a sister and a friend, as emergency contacts. During a review of Resident 58's Minimum Data Set Assessment (MDS, an assessment tool used to direct resident care) dated 2/5/25 indicated a…

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

Based on interview and record review, the facility failed to follow its policy and procedure to immediately report alleged abuse allegations to the California Department of Public Health (CDPH) and the Ombudsman within two hours for one of 27 sampled residents (Resident 92), when Resident 92's sister alleged a Registered Nurse (RN) called Resident 92 stupid. These failures had the potential to cause a delay in investigations and affect physical and psychological well-being of residents. Findings: A review of Resident 92's admission Record printed 3/27/25, indicated Resident 92 was admitted to the facility in September 2023 with a diagnosis of chronic pain. During an interview on 3/26/25, at 1:25 p.m. with RN 1, RN 1 stated, on 2/9/25 Resident 92's sister notified RN 1 that an unknown nurse called Resident 92 stupid. RN 1 stated they did not complete and submit a Report of Suspected Dependent Adult/Elder Abuse (SOC 341), to the ombudsman or CDPH. RN 1 stated they did not notify the ombudsman or CDPH of the alleged abuse. During an interview on 3/26/25, at 3:25 p.m. with Medical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 services to meet professional standards of quality for two of two sampled residents (Resident 12 and 37) when: 1. Licensed Vocational Nurse (LVN) 1 was not knowledgeable of the correct indication, dosage, and administration procedure of Resident 12's rivastigmine (medication used to treat mild, moderate, and severe dementia (memory loss and mental changes) associated with Alzheimer's disease (a brain condition that slowly damages your memory, thinking, learning and organizing skills) transdermal (the application of a medicine or drug through the skin, typically by using an adhesive patch, so that it is absorbed slowly into the body) patch. These failures resulted in Resident 12 to receive inadequate dosage of rivastigmine and not according to manufacturer's specification. 2. Resident 37's lidocaine patch (medication to ease pain by numbing the nerves and making them less sensitive to pain) was not applied per physician orders 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, interviews, and record reviews, facility failed to provide assistant for one out of two sampled residents(Resident 193), when Resident 193 who is dependent on staff was not assisted with setting up his meal tray and given required assistant with eating during lunch period. This failure resulted in Resident 193 not being able to eat and enjoy his meals at his own desire time, had his meal cold, challenges eating with his left non-dominant hand, and potential to not maintain good nutritional status and poor quality of care. Findings: During an observation and interview on 3/24/25 at 1:12 p.m.with Resident 193, Resident 193 was sitting up dangling at the bedside awaiting his lunch tray. Resident 193 had a white hard rubber cast to his right arm from his right shoulder down to his mid forearm, and a splint to the right arm down to his fingers. Resident 193 stated he had a gun shot wound to his right shoulder and abdomen which made it very difficult for him to feed himself with his left hand.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, for two of four sampled residents (Resident 8 and Resident 9) who were reviewed for range of motion/mobility needs, the facility failed to provide appropriate treatment and services to prevent further decrease in range of motion when Restorative Nursing Assistant (RNA) services ( RNA program, focuses on nursing interventions that help residents in long-term care maintain or regain their ability to perform activities of daily living (ADLs) and improve their overall well-being) was not provided as indicated in the comprehensive care plan. This failure had the potential to result in further decline in range of motion. Findings: During a review of Resident 8's admission Record (AR), the AR indicated, Resident 8 was admitted to the facility in July 2023 with diagnoses that included hemiplegia (a condition caused by brain damage or spinal cord injury that leads to paralysis on one side of the body) and hemiparesis (a condition characterized by weakness on one side of the body, making it hard to perform everyday activities like eating or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, for two of 27 sampled residents (Resident 58 and Resident 90), the facility failed to ensure an environment that is free of accident hazards as possible, and that each resident receives adequate supervision when: 1.Resident 58's bed wheels did not lock. This failure had the potential to result in preventable falls. 2.Resident 90 was not supervised while out smoking. This failure had resulted in Resident 90 leaving the facility premises undetected. Resident 90's whereabouts remain unknown. Findings: 1. During a review of Resident 58's admission Record (AR), the AR indicated, Resident 58 was admitted to the facility in January 2025 with diagnoses that included epilepsy (a brain disease where nerve cells don't signal properly, which causes seizures), hemiplegia (a condition characterized by paralysis or weakness on one side of the body) and hemiparesis (weakness or the inability to move on one side of the body, making it hard to perform everyday activities like…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, for one of eight sampled residents (Resident 87) reviewed for nutrition and hydration concerns, the facility failed to ensure Resident 87 maintained proper hydration status when fluid restriction was not followed as ordered. This failure had the potential to result in fluid retention and fluid overload. Findings: During a review of Resident 87's admission Record, the admission Record indicated Resident 87 was admitted to the facility in February 2025 with diagnoses that included congestive heart failure (a condition where the heart muscle is weakened and cannot pump blood effectively). During a review of Resident 87's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 3/8/25 indicated a Brief Interview for Mental Status (BIMS, a scoring system to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) score of 15. A score of 13-15 is an indication of intact…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, record reviews for one of two residents( Resident 83), facility failed to follow their policy and procedure when nursing staff infused Resident's 83's Jevity tube feed at the correct rate and dose as per the Physician's order, stopped Resident 83's Percutaneous endoscopic gastrostomy (PEG[a tube that is passed into a patient's stomach sugically through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate]) tube feedings without flushing the PEG immediately after, and left the tubing connected to Resident 83 for up to one hour after the infusion was completed. This failure has the potential for Resident 83's PEG tube to clog up, complications with PEG tube, infection, possible tube replacement, and hospitalization. Findings: During a review of resident 83's Facesheet (FC), FC indicated Resident 83 is [AGE] years old admitted to the facility in January 2025. The FC further indicated Resident 83 has a diagnosis Dysphasia (difficulty…

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

Based on observation, interview and record review, the facility failed to ensure residents were free from significant medication error for one of five sampled residents (Resident 12) during medication administration observation when: 1. Resident 12 did not receive Digoxin (medication to treat congestive heart failure (CHF, a condition where the heart muscle is weakened and cannot pump blood effectively) and heart rhythm problems) and Furosemide (medication used to treat fluid build-up and swelling caused by CHF and treats high blood pressure) as ordered by the physician. 2. Resident 12's physician was not informed of the significant medication error. These failures resulted in Resident 12 to experience significant medication error from the omitted (a dose of medication that is ordered but not given) dose of digoxin and furosemide. Findings: 1. During a review of Resident 12's undated admission Record, the admission Record printed on 3/25/25 indicated, Resident 12 was admitted in the facility in January 2016 with a diagnosis of atrial fibrillation (a common heart rhythm disorder…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, for one of six sampled residents (Resident 87), the facility failed to provide menus that meet residents' nutritional needs when Resident 87 was not provided double portion as ordered. This failure had the potential to result in weight loss. Findings: During a review of Resident 87's admission Record, the admission Record indicated Resident 87 was admitted to the facility on [DATE] with diagnoses that included gastro-esophageal reflux disease (GERD, is a common digestive disorder where stomach contents, including acid, flow back up into the esophagus, causing symptoms like heartburn and other digestive issues) and unspecified protein-calorie malnutrition. During a review of Resident 87's Order Summary Report dated 3/25/25, the Order Summary Report indicated a physician's order dated 2/24/25 for No Added Salt (NAS) diet regular texture, regular consistency double portion with extra gravy/sauce. During a review of Resident 87's Minimum Data Set (MDS, an assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, for one of eight residents (Resident 20) reviewed for concerns regarding food, the facility failed to provide nourishing bedtime snacks to Resident 20, a diabetic, consistent with plan of care and resident's request. This failure had the potential to result in hypoglycemia (abnormally low blood sugar level). Findings: During a review of Resident 20's admission Record (AR), the AR indicated Resident 20 was admitted to the facility in October 2024 with diagnoses that included diabetes mellitus (a chronic metabolic disorder characterized by high blood sugar levels). During a review of Resident 20's diabetes care plan dated 10/29/24 last revised 2/20/25, the care plan indicated a goal for Resident 20 to be free from any signs and symptoms of hypo/hyperglycemia (abnormally low/high blood sugar levels). Interventions included for staff to Discuss mealtimes, portion sizes, dietary restrictions, snacks allowed in daily nutritional plan. During an interview on 3/24/25 at 11:15 a.m.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to operate and provide services in compliance with State regulations when an unusual occurrence of a successful elopement by a resident was not reported to the State Agency. This failure had the potential to result in the lack of oversight for resident safety. Findings: During a review of Resident 90's AR, the AR indicated Resident 90 was admitted to the facility on [DATE] with diagnoses that included old myocardial infarction (a medical emergency that occurs when blood flow to the heart muscle is blocked, causing damage or death of heart tissue), need for assistance with personal care, depression (a common mental health condition characterized by persistent feelings of sadness, loss of interest, and low energy levels) and history of traumatic brain injury (TBI, a brain injury caused by an external force, such as a blow to the head. TBIs can cause physical, cognitive, emotional, and behavioral effects). The following were documentation by multiple staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide documentation for pneumococcal and influenza immunization screening (education, offered, and refusal of vaccine) for three of five sampled residents, Resident 14, Resident 67, and Resident 52. This failure has the potential for Resident 14, Resident 67, and Resident 52 to have infection, the spread of infection among other residents, hospitalization, and possibly death. Findings: During an interview on 3/27/25 at 09:35 a.m. with Infection Preventionist (IP), IP stated she had no records of PNA (pneumonia) and Flu (influenza) vaccine screening offered to or refusal of vaccines to Resident 14, Resident 67, and Resident 52. IP stated she or the previous facility IP did provide the consent for the vaccine, but it was not documented in the chart or point click care (PCC, an electronic medical record). IP stated it was important to have documentation of vaccination whether offered, refused, or given to Residents and their Responsible…

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

Based on interview and record review, the facility failed to develop and maintain an effective training program for all new and existing staff consistent with their expected roles based on the facility assessment when Licensed Vocational Nurse (LVN) 3 did not have annual competency training and two of three Certified Nursing Assistants (CNAs) did not have dementia training since hire date. This failure had the potential to result in providing poor quality and unsafe resident care. Findings: During a review of facility's Facility Assessment Tool, undated, the Facility Assessment Tool indicated the facility is accepting and treating residents with the following conditions: psychiatric and mood disorders like depression ( common and serious medical illness that negatively affects how you feel, think, act, and perceive the world, often causing persistent sadness, loss of interest, and difficulty with daily activities), impaired cognition, psychosis (a condition where individuals experience a loss of contact with reality, often involving symptoms like delusions (false beliefs) and…

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

Based on interview and record review, the facility's failed to ensure their skilled nursing licensed staff provided care based on professional standards for one of three sampled residents (Resident 1) when licensed nurse did not immediatelly assess and notify the doctor following Resident 1's fall. This failure resulted in unnecessary pain and a delay in treatment for Resident 1's fractured hip. Findings: During a record review of the Resident 1's clinical document titled, admission Record dated 2/6/2025,the admission record showed, the facility admitted Resident 1 in September 2019. Resident 1 had multiple medical diagnoses including hemiparesis and hemiplegia following a cerebral infarction(weakness and paralysis due to a stroke). Record review of the Resident 1's clinical document titled, Progress Notes dated 1/13/2025, the document showed, Physical Therapy Assistant (PTA) had a session with Patient 1 on 1/10/2025 between 1:30 p.m to 2 p.m. Patient 1 had agreed to the plan of sitting at the edge of the bed to promote trunk (core) strength. Patient 1 was assisted into a sitting…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 allow two of four residents (Resident 1 and Resident 2) to exercise their rights to self-determination when they were not provided nutrition in accordance with their preferences. These failures had the potential to result in Residents 1 and 2 feeling upset and disrespected. Findings: During a review of Resident 1's admission Record, printed 1/23/25, the record indicated, Resident 1 was admitted to the facility in October 2023 with a diagnosis of Adult Failure to Thrive (a syndrome that describes a decline in health in older adults characterized by weight loss, poor nutrition, and a general decline in the ability to perform daily activities). During a review of Resident 1's Brief Interview for Mental Status (BIMS, is a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.), dated 1/16/25, the record indicated, Resident 1's BIMS score was…

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

Based on observation, interview, and record review, the facility failed to treat one of four sampled residents (Resident 1) with respect and dignity when the Rehabilitation Coordinator (RC) informed Resident 1 he was being kicked out from the facility. This failure resulted in Resident 1 feeling upset and disrespected. Findings: During a record review of Resident 1 ' s admission Record, printed on 1/13/25, the record indicated, Resident 1 was admitted to the facility in November 2023 with diagnosis of end stage renal disease (last stage of long-term kidney disease). During a review of Resident 1 ' s Brief Interview for Mental Status (BIMS, is a scoring system used to determine the resident ' s cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.), dated 11/8/24, the record indicated Resident 15 ' s BIMS score was 15. Based on concurrent observation and interview on 1/9/25 at 11:11 a.m. with Resident 1, Resident 1 was in his room. Resident 1 stated he had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 of three sampled residents (Resident 1) received Gabapentin (a medication used to treat nerve pain) as ordered by their physician. This failure had the potential to cause Resident 1 unnecessary pain. Findings: During a review of Resident 1's admission Record, printed 1/10/25, the record indicated Resident 1 was admitted to the facility in December 2024 with a diagnosis of Neuralgia (a sharp, shock-like pain that follows the path of a nerve) and Neuritis (inflammation of the nerves). During a review of Resident 1's Doctors Order, dated 12/6/24, the Order indicated Resident 1 had a prescription for Gabapentin Oral Capsule 100 MG . Give 2 capsule by mouth in the evening for Neuropathy pain. The Order indicated it was Everyday. During a concurrent interview and record review on 1/10/25, at 2:03 p.m., with Assistant Director of Nursing (ADON), Resident 1's Progress Notes, dated 12/23/24 and 12/28/24 were reviewed. Resident 1's Progress Note, dated 12/23/24 indicated Gabapentin . on order. Resident 1's Progress Note,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that one of three sampled residents (Resident 2) was free from physical abuse when Resident 1 threw a flower vase to her roommate Resident 2. This failure resulted in Resident 2 having a wound in her lip and transfer to an acute care hospital for treatment. Findings: Review of Resident 1's Facesheet (information containing contact details, brief medical history at-a-glance) indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that included dementia (memory loss and impaired decision-making capacity) and delusional disorder (a serious mental illness characterized by a person having one or more false beliefs). Review of Resident 1's Minimum Data Set (an assessment tool) dated 9/17/24, indicated she had a brief interview for mental status or BIMS of 12 (BIMS score of 8 to 12 indicates moderate cognitive impairment). The MDS also indicated Resident 1 had physical and verbal behavior symptoms directed toward others. 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 observation, interview, and record review, the facility failed to ensure food was stored and prepared in clean and temperature-controlled environment, within standards for safety when: 1. Walk-in fridge temperature range was 40-48 degrees Fahrenheit (ºF), 2. Beverages not labeled or were being stored in temperatures above 40 ºF, 3. Four packages of ground beef where thawing in walk in cooler, not dated, with no thaw log, 4. Temperature of kitchen ranged 85 to 98 ºF and temporary portable air conditioner (AC) unit, placed in center of kitchen, was not cooling environment, and 5. Portable kitchen AC, placed in center of kitchen, had a grill covered in lint/dust/dirt and had not been cleaned in over a month. These failures had the potential to result in contamination of food leading to food borne illness, for 90 residents who resided in the facility. Findings: 1. During an observation in the kitchen on 9/24/24 at 11:30 a.m., the temperature of the walk-in fridge was 43 ºF, 48 ºF at 11:55 a.m. and 48 ºF 12:10 p.m. 2. During an observation in the kitchen on 9/24/24 at 11:30…

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

Based on interview and record review, the facility failed to provide written notification before a room change to Resident 1 when the resident was moved to another room without a written notification of the reason of the move. This failure violated the right of Resident 1 to receive a written notice explaining the reason for the move before the room change. Findings: During a review of Resident 1's Minimum Data set (MDS, a resident assessment tool that is used to develop a plan of care), dated 7/28/24, the MDS indicated Resident 1 was cognitively intact. During an interview on 9/18/24, at 10:31 a.m., with Resident 1, Resident 1 stated she was informed she was moving to another room on 5/24/24 and was moved on the same day. Resident 1 stated she was not given a written notice for the reason of the room change before she was moved. Resident 1 further stated she felt she was not given enough time before the room change. During a concurrent interview and record review, on 9/18/24, at 2:29 p.m., with Social Service Director (SSD), Notification of Room Change, dated 5/24/24 was reviewed.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure one of one sampled resident (Resident 1) was allowed to return to the facility after admission to the Acute Care Hospital 1 (ACH 1). This failure had the potential for Resident 1 to experience psychosocial distress regarding not being able to return to the facility. Findings: During a record review of Resident 1's admission Record, dated 7/27/24, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body), dysphagia (difficulty swallowing), and chronic obstructive pulmonary disease (a lung disease that causes obstructed airflow from the lungs). During record review of Resident 1's Hospitalist Progress Note dated 7/29/2024, the Hospitalists Progress Note indicated Resident 1 was admitted to the ACH 1 for concerns of a stroke. The progress note indicated Resident 1 had severe cervical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify (Resident 1) Physician and representative of a significant change in Resident 1's health condition of one out of two sampled residents after Resident 1 exhibited signs of difficult breathing. This failure to report significant change in Resident 1's health condition may result in delay of treatment. Findings: During review of Resident 1's Face Sheet, Face Sheet indicated Resident 1 was admitted to the facility in 2019. The Face Sheet also indicated Resident 1 had a responsible party (RP 1) for emergency contact and financial decisions. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool use to guide care) dated 11/28/23, the MDS indicated Resident 1 had a score of six on the Brief Interview for Mental Status exam. (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that two of three sampled residents (Resident 1 and Resident 2) were provided foot care and treatment. Resident 1 and Resident 2 had dark brown colored long, curved, thick toenails on both feet. Resident 1 and Resident 2 did not receive podiatry services at least four months since their admission to the facility in 10/2023. This failure resulted in Resident 1 not being able to wear socks, unable to stand or walk due to discomfort from her toenails. This failure also resulted in Resident 2 experiencing discomfort from linen/sheets and blanket touching her long toenails which made Resident 2 feel depressed and uncared for, sad and uncomfortable. Findings: 1) During a record review of Resident 1 ' s admission face sheet dated 10/10/23, the facesheet indicated Resident 1 was admitted to the facility on [DATE] with diagnosis of diabetes. During a record review of Resident 1's Minimum Data Set (MDS, an assessment used to guide plan 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 report the allegation of sexual abuse of 8/26/23 for one Resident (Resident 1) to the Adult Protective services, the local Ombudsman and California Department of Public Health (CDPH); and to the responsible party (RP) of Resident 1. The facility also failed to report the allegation of sexual abuse for Resident 1 within two hours to CDPH. The facility failed to report the results of all investigations of the allegations of sexual abuse for Resident 1 to California Department of Public Health within five working days. These failures could have resulted in further potential abuse. Findings: Resident 1 was admitted with diagnoses including Alzheimer's disease (is a type of dementia that affects memory, thinking and behavior, bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), and bilateral osteoarthritis of knee. During a telephone interview on 9/14/23, at 4:17p.m., with Resident 1's Responsible party (RP), RP stated the facility did not notify him about Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a safe environment for one resident (Resident 1) while the investigation of an alleged sexual abuse was in progress when Resident 2 was found in Resident 1's room on 9/1/23 at 4:30 a.m. There was no evidence that the facility thoroughly investigated first alleged sexual incident that occurred on 8/26/23 as there were no investigation records provided. These failures had the potential to have resulted in a further potential abuse. Findings: During a review of Resident 1's face sheet, the face sheet indicated, Resident 1 was admitted with diagnoses including Alzheimer's disease (is a type of dementia that affects memory, thinking and behavior, bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), and bilateral osteoarthritis of knee. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 that adequate call light system was provided for five out of 19 sampled residents (Resident 1, 8, 28, 52, and 59) when: 1. Resident 1, 28, 52 and 59's call light was not within reach. 2. Resident 1's call light system was not functioning. 3. Resident 8 did not have a call light. This failure resulted in Resident 1, 8, 28, 52 and 59 not having direct access when seeking assistance from the staff. Findings: 1. During a concurrent observation and interview on 8/21/23 at 11:14 a.m. with Registered Nurse (RN) 3 in Resident 59 and 52's room, it was observed that Resident 59's call light is on the floor behind Resident 52's bed and Resident 52's call light was tied in a coil hanging on the wall where it is plugged. RN 3 stated, that call lights need to be next to the resident and it is not acceptable that it is not within their reach. RN3 uncoiled Resident 52's call light and clipped it on the blanket and picked up Resident 59's call light from the floor and placed it next to Resident 59. RN3 stated, that…

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

Based on observation, interview, and record review, the facility failed to ensure one of three sampled resident (Resident 31), was shaved in accordance with their preferences. This failure had the potential to result in Resident 31 feeling disrespected and upset. Findings: During an interview on 8/21/23, at 11:51 a.m., with Resident 31, Resident 31 stated, on 8/21/23 Certified Nursing Assistant (CNA) 1 didn't follow directions when shaving his mustache and beard. Resident 31 stated, he told CNA 1 to shave him with the grain and not go against the grain. Resident 31 stated, CNA 1 shaved him against the grain after he told him to shave with the grain. Resident 31 stated, he has tender skin and chronic shaving bumps. Resident 31 felt disrespected and upset. During an interview on 8/21/23, at 12:37 p.m., with CNA 1, CNA 1 stated, he shaved Resident 31's face on 8/31/23 with short strokes up against the grain and long strokes down with the grain. CNA 1 stated, Resident 31 told him, he only wanted to be shaved with downward strokes with the grain. CNA 1 stated, he used a one-time use…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, it is evident that the facility has not successfully secured the services of a licensed pharmacist who can provide comprehensive consultation encompassing all facets of pharmacy services. This deficiency is notably reflected in the consistent occurrence of high medication error rates, surpassing the acceptable threshold of 5% during monthly medication passes. Additionally, no discernible plan has been established to rectify and reduce these concerning medication error rates. Findings: During a medication pass observation conducted on 8/22/23, spanning from 7:20 AM to 11:00 AM, three medication errors surfaced out of twenty-five opportunities. Consequently, an error rate of 12% was recorded. It is pertinent to note that the three errors materialized across three nurses administering medications (refer to F759). A review on 8/22/23, of the Summary of Nursing Consultant Report unveiled insights gleaned from medication pass observations. This report encompassed observations conducted throughout the months of June, July, and August. The documented…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 that one of 19 sampled residents (Resident 36) drug regimen was free of unnecessary drugs when Resident 36 had a duplicate order for Aspirin (ASA-a non-steroidal anti-inflammatory medicine that is also used in the prevention of strokes.) This deficient practice resulted to Resident 36 receiving twice the prescribed dose of ASA and had the potential to put Resident 36 at increased risk for bleeding. Findings: A review of Resident 36 admission record, the record indicated, admit date 1/23, with diagnoses including cerebral infarction (disrupted blood flow to the brain due to problems with blood vessels) and congestive heart failure (condition in which heart does not pump blood as well as it should) During a concurrent interview and record review on 8/24/23 at 9:16 a.m. with DON, Resident 36's electronic Medication Administration Record (eMAR-used to document medications taken by each individual), dated 6/1/2023-6/30/2023 was reviewed. The eMAR indicated that the resident has an active order for Aspirin 325mg tab give…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the data gathered from observations, interviews, and record reviews, it was determined that the facility fell short of maintaining a medication error rate below 5%. Within the medication pass process, a total of three medication errors were witnessed out of twenty-five opportunities, resulting in a notable error rate of 12%. Findings: 1. An evaluation conducted on 08/22/23 of Resident 28's electronic clinical record disclosed that physician's orders were in place for intravenous (IV) Meropenem 1 g, to be administered thrice daily. Meropenem, an antibiotic utilized to combat bacterial infections, is administered through intravenous infusion. During an observation conducted on 08/22/23 at 7:30 AM, RN 1 prepared an IV solution of Meropenem by combining a 1 g vial of the medication with 50 mL of sodium chloride within the mini bag plus container system. The mini bag plus container system necessitated assembly by attaching it to the vial of Meropenem. A review of the manufacturer's instructions for the Mini Bag Plus container system stipulated that once the 1g vial of Meropenem…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and interviews, it is evident that the facility fell short in ensuring the proper storage of refrigerated medications. This issue came to light when a malfunctioning refrigerator thermometer was discovered within the medication refrigerator. Findings: During an observation conducted on 8/22/23 at 12:30 PM, a range of medications was found stored within the medication refrigerator. Within the refrigerator door, a thermometer was affixed, intended to monitor the internal temperature. Regrettably, the thermometer appeared to be damaged, with its liquid content hindering an accurate reading of the temperature. During the interview on 8/22/23 at 12:32 PM, RN 2 acknowledged the malfunction of the thermometer within the medication refrigerator. RN 2 acknowledged the significance of precisely monitoring temperatures and expressed a commitment to promptly addressing the issue. It is imperative to appropriately store medications that necessitate refrigeration. In cases where temperatures are either excessively low or high, these medications are susceptible 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.

Based on observation, interview, and record review, for one of 22 sampled residents (Resident 40), the facility failed to develop a care plan for the use of a hand mitt (soft fiber-filled mitten with tie wrist closure are indicated for patients who are prone to self-injury or who disrupt medical treatment). This failure had the potential to cause Resident 40 a decline in the physical functioning of her left hand or skin breakdown. Findings. A record review of Resident 40's admission Record indicated the resident was admitted to the facility with multiple diagnoses, including aphasia (loss of the ability to understand or express speech, caused by brain damage), and Non-Alzheimer's Dementia (impaired judgement. The record review of Resident 40's Brief Interview for Mental status (BIMS, a tool to assess mental function) in the Minimum Data Set (MDS, an assessment tool to guide care) dated 10/2/19, indicated the resident's score was 00, meaning she was severely, cognitively impaired. During an observation on 11/12/19 at 11:05 a.m., Resident 40 had a left hand mitt on. During an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 skilled nursing facility did not provide the necessary care for three of 22 sampled residents (Residents 5, 27 and 279). Resident 5 complained of shortness of breath which was not addressed. Patient 27's bed was not elevated to the prescribed level while being administered liquid medication into his Gastrostomy Tube (G Tube), a tube surgically placed into the abdomen to administer liquid food or medication), and Resident 279 complained of pain which was not treated in a timely manner. These failures resulted in unnecessary pain and difficulty breathing for Resident 5, delayed pain management for Resident 279, and the potential for aspiration (fluid into the lungs) for Resident 27. Findings: 1. A record review on 11/14/19 of the Face sheet indicated the diagnoses included chronic obstructive lung disease (breathing problems). The record review of the Medication Administration Record dated November 2019 indicated Resident 5 was to receive an albuterol inhaler (fast acting breathing medication), every four hours as needed for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the Performance Evaluation policy and procedure when the Director of Staff Development (DSD) did not conduct the following: 1. A 90-day post probationary period performance evaluations for one of three Licensed Vocational Nurses (LVN 1) and, 2. An annual performance evaluation for one of two Registered Nurses (RN 1). This failure did not ensure the employees competency and skills were met to provide safe care. Findings: A record review of the employee files on 11/15/19 reflected the following: 1. LVN 1 was hired on 5/21/19. Further review of the employee file indicated there was no 90-day post probationary period performance evaluation conducted for LVN 1. 2. RN 1 was hired on 8/11/16. Further review of the employee file indicated there was no annual performance evaluation conducted for RN 1. During an interview and concurrent record review on 11/15/19 at 10: 22 a.m., the DSD stated there were no Quarterly Skills Check (90-day post probationary period performance evaluations) conducted and no Annual Competency…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 conduct a Certified Nursing Assistant (CNA) annual competency check for one (CNA 1) of one sampled employee. CNA 1 did not have the annual competency checks or complete a 12 hour/year in-service training as required. This failure did not ensure CNA 1 had the necessary skills and training needed to provide safe resident care. Findings: A record review of the employee file for CNA 1 indicated the date of hire was 5/1/14. Further review reflected there were no annual performance evaluations conducted for CNA 1. During an interview and concurrent record review on 11/15/19 at 10:22 a.m., the Director of Staff Development (DSD) stated there was no annual competency skills check for CNA 1 or documentation of having completed a 12 hours/year in-service training as required for 2018 and 2019. Sufficient and Competent Nurse Staffing 11/15/19 10:22 AM with DSD [NAME] [NAME] LVN- hire date - 5/21/19. There was no 90 day competency evaluation done for her [NAME] RN…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the medication for one (Resident 230) of 25 sampled residents was administered correctly and as prescribed. The nursing staff administered Resident 230's oral inhaler (medication used to improve breathing) without proper instructions. This failure resulted in Resident 230 not receiving the full dose and effectiveness of her inhaled respiratory medication. Findings: 1. A record review of the document Facesheet showed the facility admitted Resident 230 on 10/15/19. The diagnoses included Chronic Obstructive Pulmonary Disease (COPD, a breathing disorder). The record review of the Physician's Telephone Orders dated 11/12/19 indicated,Start Fluticasone/Salm (also known as Advair Diskus) 250-50 mcg (micrograms) inhale 1 puff PO (orally) BID (twice a day). Rinse mouth after each use. The record review of the MDS 3.0 . (resident assessment) showed Resident 230 was alert and could identify the correct year, month and day and able to understand others. During the medication pass at 10:22 a.m. on 11/14/19, LVN 1…

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

Based on observation, interview, and record review, the facility failed to follow the policy and procedure for infection control when nursing staff failed to perform hand hygiene between glove changes for one (Resident 78) of 22 sampled residents. This failure increased the potential for the transfer of germs and infection. Findings: During an observation of the wound dressing change for Resident 78, with Licensed Vocational Nurse 2 (LVN 2) on 11/14/19 at 9:15 a.m., LVN 2 had removed multiple gloves from the dispensing box and stored them in her pocket with her treatment keys. LVN 2 donned a pair of gloves taken from her pocket to remove the old dressing from Resident 78's coccyx. LVN 2 repeatedly used multiple gloves taken from her pocket without washing her hands during the entire course of the wound dressing change. During an interview with LVN 2, on 11/14/19 at 10:30 a.m., LVN 2 stated she should be washing her hands before and after removing the gloves, and not be putting gloves in her pocket. A record review of the policy and procedure titled, Personal Protective Equipment…

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