Ojai Health & Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility failed to ensure Resident 1's drug regimen was free from unnecessary medications when Resident 1's physician order for lidocaine patch (a topical medication that delivers local anesthetic directly to the skin to provide temporary relief for localized muscle, joint, or nerve pain) exceeded manufacturer's instructions. This failure had the potential for Resident 1 to receive more than the recommended dose per manufacturer's recommendations. During a review of Resident 1's admission Record (AD), the AD indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that include cerebral infarction (the death of brain tissue as a result of reduced or blocked blood flow), hemiplegia and hemiparesis (complete paralysis and weakness) affecting right dominant side, generalized muscle weakness, and depression (persistent sadness, loss of interest in activities, and low energy). During a review of Resident 1's Order Summary Report, dated 4/8/26, indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the comprehensive care plan (CP - written document that outlines the specific nursing interventions and goals for a patient's care, based on their assessed needs and diagnoses) for pain was updated to reflect the resident's current care needs and interventions for one of three sampled residents (Resident 1). This failure had the potential to result in inadequate pain management and could negatively impact Resident 1's psychosocial wellbeing.During a review of Resident 1's admission Record (AD), the AD indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that include cerebral infarction (the death of brain tissue as a result of reduced or blocked blood flow), hemiplegia and hemiparesis (complete paralysis and weakness) affecting right dominant side, generalized muscle weakness, and depression (persistent sadness, loss of interest in activities, and low energy).During an observation and interview on 4/8/26 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide the necessary care and services for one of three sampled residents (Resident 2) to ensure the resident maintained the highest physical well-being; when there were no Physician's Orders that addressed hospice care (program that gives special care to people who are near the end of life), the use and care of a urinary catheter (a flexible tube that collects urine form the bladder and collected in a drainage bag), and use, care, discontinuation, and monitoring for a Peripherally Inserted Central Catheter (PICC- a long, thin tube that's inserted through a vein in the arm). This failure had the potential to result in Resident 2 not receiving necessary care and services consistent with their health status.During a review of Resident 2's Clinical Record (CR) indicated Resident 2 was admitted to the facility on [DATE] under hospice with diagnoses that include cerebral infarction (the death of brain tissue as a result of reduced or blocked…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record review and staff interview, the facility failed to ensure compliance with the required 3.5 direct care hours per patient day, resulting in insufficient staffing on 2 of 28 days reviewed.This failure had the potential to result in unmet care needs, inadequate supervision, delayed response to changes in condition, and avoidable adverse outcomes for residents. A review of the facility's Direct Care Hours Per Patient Day (DHPPD) staffing logs for the month of 2/1/26 - 2/28/26 , showed the facility reported the following direct care hours: 2/2/26 - 3.40 hours 2/8/26 - 3.46 hoursThe records confirmed that 2 of 28 days reviewed, the facility failed to meet the staffing minimum of 3.5 DHPPD.During an interview on 4/2/26 at 11:40 a.m. with Director of Nursing (DON), stated to be aware of the 3.5 DHPPD staffing requirement, but were not aware that the facility did not the staffing minimum of 3.5 DHPPD requirement for the month of February 2026. A review of the facility's program waiver for staffing, dated June 2, 2025, (A program waiver for staffing is an authorized exception…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 adequate supervision for one of two sampled residents (Resident 1), when Resident 1 was identified as at risk for elopement, left facility without knowledge of staff, and was found a block from the facility.Findings:During an interview on 9/25/25 at 1 p.m. with the director of nursing (DON), the DON stated, We didn't realize Resident 1 was missing until the fire department brought him back. He wasn't gone from the facility that long, so we didn't think reporting to CDPH was necessary. During an interview on 9/25/25 at approx. 1:30 p.m. with Certified Nursing Assistant 2 (CNA 2), CNA 2 verbalized, heard the wander guard alarm sound, checked the back door of the facility, did not see any residents, assumed it was a false alarm and did not realize a resident was missing until the fire department showed up.During an interview on 10/8/25 at 8 a.m. with [NAME] County Fire Captain (FC), the FC stated, When we arrived on scene there was a gentleman…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 comply with the state requirement of unusual occurrence by not reporting to the Department (State Agency) for one of two sampled residents (Resident 1). When a Resident with a history of dementia left the care facility without knowledge to staff, fell and was transported to emergency department.This deficient practice resulted in a delayed investigation by the Department.Findings:During an interview on 9/25/25 at 1 p.m. with the director of nursing (DON), the DON stated, We didn't realize Resident 1 was missing until the fire department brought him back. He wasn't gone from the facility that long, so we didn't think reporting to CDPH was necessary. During an interview on 9/25/25 at approx. 1:30 p.m. with Certified Nursing Assistant 2 (CNA 2), CNA verbalized, they heard the wander guard alarm sound, checked the back door of the facility, did not see any residents, assumed it was a false alarm and did not realize a resident was missing until…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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: 1. Ensure four employees working as Certified Nursing Assistants (CNAs 1, 2, 3, and 4) had valid and up-to-date CNA certifications. 2. Ensure two employee personnel files (CNAs 1and 3) were complete and up to date.These failures resulted in unlicensed CNAs providing direct care to residents without proper certification and placed residents' safety at risk.1. During an interview on [DATE] at 10:05 a.m. with the Director of Staff Development (DSD), DSD stated the CNA is responsible for maintaining up to date certification and I double check with the files. DSD further stated we had to check three or four months ago and knew the CNAs who were about to expire and reminded them to get it done and that they can't be on the schedule, it's paper tracking and we keep a schedule of who is due. We will let them know when it will expire and prompt them again and when they get the certification, they will bring it in. We only go online to verify if it's expiring…

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

Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent accidents while smoking for one of four sampled residents (Resident 2). This failure had the potential for residents to suffer significant injuries. During an observation on 5/30/25 at 8:35 a.m. while walking up to the front entrance of the facility, Resident 2 was observed lying in the street after sustaining a fall from his wheelchair after going off the curb of the sidewalk while alone in the front of the facility to smoke a cigarette. The surveyor walked into the facility to look for staff to get assistance but was unable to locate any staff members. The surveyor walked down the hall to the nurse's station and alerted Charge Nurse (CN) of Resident 2 lying in the street next to his wheelchair. Observed multiple staff running out of the facility to assist the resident back into his wheelchair and assess Resident 2 for injuries. Followed staff outside to the front of the facility to observe. Resident 2 was yelling at staff to leave him alone and not to call 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 record review and interview, the facility failed to ensure staff observations of resident skin issues and/or conditions were consistently and accurately documented in the skin monitoring form for two of two sampled residents (Residents 1 and 2). These failures had the potential to result in inaccuracies of information which could affect the delivery of care and services for these residents affecting health and safety. Findings: During a concurrent interview and record review on 5/14/25 at 11:55 a.m., with the facility's (Interim) Director of Nursing (DON), the facility form titled, Skin Monitoring (SM): CNA (Certified Nursing Assistant) Shower Review, was reviewed. DON verbalized that the SM form is used by CNAs to document skin observations of their assigned residents during bed baths/showers. The SM form included a list of skin issues/conditions and a body chart to graph the exact location of the skin issue/condition. DON further verbalized the CNA will report the observed skin issues/conditions to the charge nurse. During a review of Resident 1's Nursing - Comprehensive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 to the California Department of Public Health (CDPH) suspicion of abuse for one resident (Resident 1). This failure had the potential to delay investigation and affect physical and psychosocial well-being of Resident 1. Findings: During an interview on 3/25/25 at 11:35 a.m. with licensed nurse (LN) 3, LN 3 verbalized heard rumors of the abuse, reported it to the former Operations Manager (FOM). The FOM requested LN 3 write a statement regarding the alleged abuse. LN 3 provided a written statement and did not report the alleged abuse further. During an interview on 3/25/25 at 1:10 p.m. with Human Resources (HR), HR verbalized FOM knew about the allegations, an investigation was conducted. The employee was terminated. they used evidence of text messages and information gathered from a phone to terminate the employee. HR thought the FOM was to notify the CDPH. During an interview on 3/25/25 at 1:30 p.m. with Director of Staff Development (DSD), DSD verbalized the information was given to the FOM and believed the FOM…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 its policies and procedure when a Certified Nurse Assistant (CNA 1) reported an alleged incident of sexual abuse for one of three sampled residents (Resident 1) to a nurse, who did not report the allegation to the administration. This failure resulted in a delay in the investigation of the alleged sexual abuse. Findings: During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, dated 2001, the P&P indicated: If resident abuse, neglect, exploitation, misappropriation of resident property, or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. During an interview on 3/13/25 at 2:11 p.m. with CNA 1, CNA 1 stated that during rounds at 6:30 a.m., Resident 1 reported that her roommate was fondled by a male staff member during a brief change last night. CNA 1 stated that she immediately reported Resident 1's allegation 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, the facility failed to ensure there was an informed consent for the use of bed rails for one of five sampled residents (Resident 4). This failure had the potential to result in Resident 4 or representative not to be given the information needed to make an informed decision. Findings: During an observation on 02/24/25 at 10:47 a.m. in Resident 4's room, Resident 4 was sleeping in bed with two full-length bed rails up. During a concurrent interview and record review on 02/26/25 at 10:48 a.m. with a Licensed Nurse (LN 1), Resident 4's electronic and paper records were reviewed. There was no evidence of an informed consent for the use of bed rails in Resident 4's electronic or paper record. LN 1 confirmed that no informed consent on the explanation of risks and benefits regarding the use of bed rails was in Resident 4's records. During a review of facility's policy and procedure (P&P) titled, Bed Safety and Bed Rails, dated May 2024, the P&P indicated, Before using bed rails for any reason, the staff shall inform the resident or…

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

Based on interview and record review, the facility failed to provide information about the right to formulate an advanced directive (a legal document that states a person's wishes for medical care if they are unable to communicate them) for four of four sampled residents (Residents 4, 18, 20, and 42). In addition, the facility failed to establish, maintain, and implement written policies and procedures regarding the residents right to formulate an advanced directive. These failures had the potential for the residents' decisions regarding their health care and treatment not being honored. Findings: During a review of Residents 4, 18, 20, and 42's admission Packet Forms, the Packets did not contain any written form indicating, a review of the process in the formulation of an advanced directive was discussed with and acknowledged by the resident or resident's representative. During an interview on 02/26/25 at 10:30 a.m. with Licensed Nurse (LN 1), LN 1 confirmed there was no written evidence regarding a discussion about advanced directives during or anytime after admission present 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: 1. The toilet grab bar in room [ROOM NUMBER] was present. 2. room [ROOM NUMBER]'s room temperature was within ideal temperature range, as per facility policy. These failures had the potential to compromise resident safety and comfort. Findings: 1. During an observation on 02/24/25 at 10:59 a.m. in room [ROOM NUMBER]'s restroom, the restroom was observed without a grab bar next to the toilet seat and on the wall were holes where the grab bar should have been. During an interview on 02/24/25 at 11:05 a.m. with Resident 42 in room [ROOM NUMBER], the resident stated using the toilet in room [ROOM NUMBER] because the bathroom in room [ROOM NUMBER] does not have a grab bar next to the toilet, making it hard to move from sitting to standing and stated mentioning the concern to the maintenance supervisor (MS) about three weeks ago. During an interview on 02/26/25 at 10:30 a.m. with the MS, MS stated not being aware of the missing grab bar…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record review and interview, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR - screening for individuals with a mental disorder and individuals with intellectual disability) Level II Evaluation (a person-centered evaluation that is completed for anyone identified as positive for Level I screening or as having or suspected of having serious mental illness, intellectual disability, developmental disability or related condition) was completed for one of four sampled residents (Resident 51). This failure had the potential to result in the resident not receiving appropriate care and services. Findings: During a review of Resident 51's admission Record (AR), dated 2/27/25, the AR indicated, Resident 51 is a [AGE] year-old male who was admitted to the facility on [DATE], with diagnoses including, disorganized schizophrenia (a mental disorder characterized by disorganized thinking, speech, and behavior), unspecified psychosis (a collection of symptoms that involves 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 record review and interview, the facility failed to ensure the care plan of one of four sampled residents (Resident 46) was revised to address the significant decline of the Brief Interview for Mental Status (BIMS - a 15-point cognitive screening measure that evaluates memory and orientation impairments in older adults; 0-7 points suggests severe cognitive impairment, 8-12 points suggests moderate cognitive impairment, 13-15 points suggests cognition is intact) scores of the resident. This failure had the potential to result in appropriate care and services not being provided to the resident. Findings: During a review of Resident 46's, admission Record (AR), dated 2/27/25, the AR indicated in part, Resident 46 is a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including, Wernicke's encephalopathy (a brain and memory disorder due to a lack of Vitamin B1 requiring immediate treatment) and major depressive disorder (a mood disorder that affects how a person feels, thinks,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 sampled residents (Resident 1) was protected from misappropriation of property when a package received was open with missing items. This failure resulted in violating Resident 1's rights to receive unopened, intact packages, and right to privacy. Findings: During a review of Resident 1's admission Record (AR), dated 11/27/24, the AR indicated, Resident 1 was admitted with diagnoses including, below the knee amputation (missing their left leg from the knee downwards), acute respiratory failure (difficulty breathing), and depression (feeling of sadness and low energy that affects quality of life.) During a review of Resident 1's, MDS (Minimum Data Sheet - a federally mandated process of clinical assessment for nursing home patients) Assessment, dated 11/5/24, the MDS indicated, Section C - Brief Interview of Mental Status (BIMS) assessment indicated, Resident 1 had a BIMS Score of 15 (The BIMS assessment uses a points…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 physician orders for one of three sampled residents (Resident 1), when a pain medication was not available within 24 hours from order date. This failure had the potential for Resident 1 to have untreated pain and hinder recovery. Findings: During a review of Resident 1's Order Summary Report (Orders), dated 10/14/24, the Orders indicated, Oxycodone HCl 20 mg tablet (controlled substance, pain medication). Give 1 tablet by mouth every 6 hours as needed for pain management. During a review of Resident 1's Medication and Administration Record (MAR), dated October 2024, the MAR indicated, the order start date was 10/15/24, but first dose of Oxycodone HCl 20 mg tablet was not given until 10/19/24. During a review of Resident 1's Controlled Drug Record, with administration dates from 10/19/24-10/30/24, the Drug Record label indicated, the fill date for the Oxycodone was 10/18/24 with first dose given on 10/19/24 at 9:50 a.m. During a concurrent interview and record review on 11/15/24 at 4:40 p.m. with Director of Nursing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to maintain a temperature range of 71-81 degrees Fahrenheit in the facility when temperatures throughout the facility measured between 64.9 and 65.2-degrees Fahrenheit, and one resident (Resident 1) was found with a plugged in space heater in their shared room. These facility failures violated all 72 resident's rights to have comfortable and safe temperatures within the facility and posed a risk for fire with a space heater in a resident ' s shared room. Findings: During a tour of the facility on 11/09/24 at 2:45 AM, the facility temperature felt cold throughout the facility even with a warm jacket on. Residents were observed with multiple blankets on sleeping. Staff were awake and were using blankets and all were wearing jackets. The resident in room [ROOM NUMBER] B had a space heater in their room. It was plugged in and the light was on, but the heater itself was off. Resident 1 was asleep in bed. During an interview on 11/09/24 at 2:55 AM with a certified…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and interview, the facility failed to follow state laws regarding name badges for employees working in the facility actively caring for residents when 6 of 7 employees working did not have name badges. This facility failure had the potential for unauthorized people to act like employees in the facility, and also prevents residents knowing who is caring for them. Findings: According to the California Business & Professional Code, under Section 680 a) except as otherwise provided in this section, a health care practitioner shall disclose, while working his or her name and practitioner ' s license status, as granted by this state, on a name tag in at least 18-point type. A health care practitioner in a practice or an office, whose license is prominently displayed, may opt to not wear a name tag. If a health care practitioner or a licensed clinical social worker is working in a psychiatric setting or in a setting that is not licensed by the state, the employing entity or agency shall have the discretion to make an exception from the name tag requirement 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow facility polices and procedures for unusual occurrence when Resident 1 was brought to the hospital for an alleged overdose of medication. This failure resulted in the facility failing to report the unusual occurrence to the California Department of Public Health. Findings: During a review of Resident 1's admission Record, the admission Record indicated, Resdient 1 was a [AGE] year-old female admitted to the facility on [DATE] with a diagnoses including, DM II (high blood sugar levels), thrombocytopenia (a condition with low number of platelets or blood component that help form clots to stop bleeding), lymphedema (a condition that causes swelling due to accumulation of watery fluid that carries nutrients, white blood cells throughout the body), repeated falls, contusion (bruise) of the knee, acute respiratory (lung) infection, history of psychoactive (a drug that causes changes in mood, awareness, thoughts, feelings or behavior)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and interview, the facility failed to ensure a resident ' s room was free from a cracked window for one out of five sampled residents (Resident 5). This failure has the potential to be a safety risk to Resident 5. Findings: During a concurrent observation and interview on 8/21/2024 at 3:31 p.m. with Resident 5 and the Director of Maintenance (DOM) in Resident 5 ' s room, a rectangular shaped window next to Resident 5 ' s bed was noted to have a crack in the glass. The crack had a starburst type pattern (small chip with several cracks radiating out of the center) and approximately 20 cracked lines which extended from the central point to three boarders of the window frame. Resident 5 verbalized they had been at the facility for about five weeks, and the window had been like that since they arrived. The DOM verbalized the window had the crack for a couple of months and it needed to be taken care of. During a concurrent interview and record review on 8/21/2024 at 3:35 p.m., with the DOM, the facility ' s policy and procedure (P&P) titled, Maintenance Service,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow physician orders for one of two sampled residents (Resident 1), as evidenced by no documentation of the following physician orders: 1. COVID-19 testing on days 3 and 5 after admission. 2. Check Temperature every shift. This failure had the potential for facility missing changes in Resident 1's health condition and a delay in treatment. Findings: 1. During a review of Resident 1's Order Summary Report (Orders), dated 3/15/24, the Orders indicated, Perform COVID-19 tests on days 1, 3, and 5 after admission. During a review of Resident 1's Medication and Administration Record (MAR), dated March 2024, the MAR indicated, only one COVID-19 test performed on 3/16/24 for day one. No licensed staff initials for days three and five. 2. During a review of Resident 1's Order Summary Report (Orders), dated 3/15/24, the Orders indicated, Check Temperature every shift. During a review of Resident 1's Temperature Summary for the month of April 2024, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to accurately post contact information with the name, addresses, and phone number for the State agency (California Department of Public Health [CDPH]) in an accessible and understandable manner and failed to ensure the posting included a statement that the resident may file a complaint with the State Survey Agency. These failures had the potential that residents rights to be informed of these agencies and services would not be supported. Findings: During an interview on 4/25/24 at 10:24 a.m. with Resident 1, Resident 1 stated, I asked the administrator for the phone number to file a complaint and they wouldn't give it to me. Resident 1 further stated, I know it's supposed to be posted somewhere. During a concurrent observation and interview on 4/25/24 at 1 p.m. with the director of nursing (DON), the Important Facility Information was observed posted in a glass display case on the wall beside the First Hall nurses station. The posted information 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 interview, observation, and record review, the facility failed to provide a safe, functional, and sanitary environment for residents, staff, and the public when the maintenance department was cluttered and trash bins were overflowing. This failure had the potential to create an unsafe environment for the residents and visitors due to possible pest infestation, spread of diseases in the facility, and exposure to hazardous materials. Findings: During an interview on 4/25/24 at 11:05 a.m. with the facility ' s maintenance staff (MS), MS indicated the maintenance department is responsible for providing services to all areas of the facility. During an observation on 4/25/24 at 11:08 a.m. MS opened a door to the maintenance department. Observations of the maintenance department and the facility ' s grounds revealed the following: 1. Multiple large cardboard boxes were piled up and overflowing with trash. 2. A broken closet door leaning against a wall, covering an open doorway. 3. Air conditioner vent covered with a black organic substance. 4. Trash bins overflowing with yard…

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

Based on observation, interview, and record review, the facility failed to maintain a safe and sanitary environment for 61 of 61 residents when: 1. The residents' drinking water dispenser contained several areas of a brown slimy substance in the drip tray. 2. The air gap vent on the ice machine had a brown grime substance and broken drain pipe. These failures had the potential to cause waterborne illness, from drinking contaminated water, in a vulnerable resident population. Findings: During an observation on 4/25/24 at 10:23 a.m. in First Hall, the residents' drinking water dispenser (a hospital-grade machine that provides safe drinking water) was observed to have a brown slimy substance in several areas of the drip tray. During a concurrent observation and interview on 4/25/24 at 10:24 a.m. with Certified Nursing Assistant (CNA), CNA stated, the water dispenser in First Hall was used by all residents was observed. CNA acknowledged the residents' drinking water dispenser was dirty and had a brown slimy substance in several areas of the drip tray. During an observation and interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide supervision and assistance for one of two sampled residents (Resident 1) during transportation to and from an appointment outside of the facility. This failure resulted in Resident 1 not waiting for transportation and leaving the appointment. Resident 1 subsequently fell out of their wheelchair near a road with heavy traffic and verbalized they did not know where they were or how to return to the facility. Findings: During a review of Resident 1's Order Summary Report (OSR), dated 2/28/24, the OSR indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses including, major traumatic brain injury (TBI) with concussion (a brain injury caused by a blow to the head), subdural hematoma (a pool of blood between the brain and its outermost covering), fractures to the mandible (Jawbone) and zygomatic arch (a bone that runs alongside of the head). Resident 1 was left with reduced mental acuity (a person's ability to make…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 adequate staffing to meet the resident's needs for seven of eight sampled residents (Residents 4, 9, 10, 11, 6, 7, and 8), when: 1. The facility did not meet required direct care service hours 15 days from 11/1/23 through 12/13/23. 2. Residents 4, 9, 10, and 11 were not given their prescribed medications for one or more shifts/days. 3. Residents 6, 7, and 8 tested positive for COVID and nursing was not documenting their progress and/or response to treatment for a minimum of 72 hours. This failure had the potential of physical or psychosocial harm due to missed medications or no documentation of residents' response to treatment. Findings: 1. During a review of the facility's Census and Direct Care Service Hours Per Patient Day (DHPPD-Document providing information on actual total direct care service hours provided to residents,) dated 11/1/2023 through 12/13/2023, the DHPPD indicated, the following dates the facility did not meet the required minimum Direct Care Service Hours of 3.5: 11/5/23, 11/11/23, 11/12/23,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 properly date and store food in refrigerators. This failure had the potential for food borne illnesses for the residents. Findings: During a concurrent observation and interview on 10/16/23 at 9:50 a.m. with the Dietary Staff (DS1), the following items in the facility refrigerator were observed not labeled and dated: Fish, bread buns and a box containing sandwiches, gelatin and fruit cups. DS1 confirmed the fish, bread buns and the box containing the sandwiches and gelatin were not labeled and dated. During a concurrent observation and interview on 10/16/23 at 9:59 a.m. with DS1, the fruit juice cups in the kitchen refrigerator were observed with a use by date of July 19, 2023. DS1 confirmed the fruit caps had expired and should have been removed. During a review of the facility's policy and procedure (P&P) titled, Leftover Foods, dated year 2023 (no month) the P&P indicated in part, 1. Storage of leftovers, a. label and date b. use refrigerated leftovers within 72 hours . During a review of the facility's P&P…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure 1 of 18 sampled residents (Resident 2) was assessed and provided with the appropriate way to self-control the overbed light. This failure had the potential for Resident 2's needs not being met. Findings: During an observation and interview on 10/16/23 at 9:40 a.m. in room [ROOM NUMBER], with Resident 2, the switch of the overbed light was attached to the light panel away from resident's reach. Resident 2 verbalized she had to rely on the nurses to turn on and off the light as it can't be reached by self. During a review of Resident 2's Minimum Data Set (MDS-a standardized assessment tool that measures health status in nursing home residents) Section C (assessment for mental status), dated 9/24/23, Resident 2's BIMS (Brief Interview for Mental Status - 0 to 7 points: suggests severe mental impairment [memory problem], 8 to 12 points: suggests moderate mental impairment, 13 to 15 points: mental intactness) was 14. During an interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure 2 of 18 residents (Residents 3 and 67) Physician's order for do not resuscitate (DNR) were in the residents' medical records. This failure had the potential for residents to not receive their healthcare choices when they were no longer capable of making decisions for themselves. Findings: 1. During a review of Resident 3's facesheet dated 10/17/23, the facesheet indicated, Resident 3 was admitted to the facility on [DATE]. During a review of Resident 3's Physician Order Summary Report, dated 8/30/23, the DNR order was not found in Resident 3's medical record. During a review of Resident 3's medical record, a Physician Order for Life Sustaining Treatment (POLST - medical order form that tells medical staff what to do if you have a medical emergency and are unable to speak for yourself) was observed. The POLST, dated 12/7/21, indicated, A. Do Not Attempt Resuscitation/DNR . B. Selective Treatment . C. No artificial means of Nutrition. The POLST…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Gastrostomy (GT- tube placed in the stomach for feeding, hydration or medicine) care was observed prior to medication administration and medications as prescribed by the attending physician were administered as ordered for 1 of 18 sampled residents (Resident 34) when: 1. GT placement was not checked prior to medication administration. This failure has the potential for the GT to be not be in the correct place which could result to medications and fluids administered going straight to the lungs causing pneumonia (lung infection). 2. Residual crushed medication was left in all 13 medication cups and not administered. This failure had the potential for the resident to not receive medications as ordered which could affect the resident's overall health. Findings: According to Nursing Made Incredibly Easy! 15(6):p 4, November/December 2017. | DOI: 10.1097/01.NME.0000525557.44656.04 ,in 2016, nursing was voted the most trusted profession…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 availability of the re-filled medication per physician's order for 1 of 18 sampled residents (Resident 34). This failure resulted in Resident 34 missing two doses of the prescribed medication and placed Resident 34's health and safety at risk. Findings: During a review of Resident 34's Order Summary Report, dated 10/17/23, the Order Summary Report indicated, a medication order for Resident 34, Carafate Oral Suspension (a liquid medication form used to treat or prevent ulcer or heart burn), give 10 ml (milliliter - unit of measurement) through a gastrostomy tube (GT - tube placed in the stomach for feeding, hydration or medicine) four times a day for Gastroesophageal reflux disease (GERD - stomach acid moves into the esophagus). During a concurrent observation and interview on 10/17/23 at 9 a.m. with the licensed nurse (LN 1), during morning med pass, LN 1 acknowledged, the unavailability of the Carafate medication. LN 1 further acknowledged, the medication was re-filled (request for additional) on…

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

Based on observation, interview, and record review, the facility failed to observe infection control practices (prevention of contamination with disease causing infection) when an open, unlabeled bottle of cleaning solution was found in the medication storage room. This failure had the potential to transmit infectious microorganisms (germ) and increase the risk of infection for residents and staff. Findings: During an observation on 10/17/23 at 8:15 a.m. in the medication storage room, an open, unlabeled bottle of Hydrogen Peroxide 3% (three percent solution used for cleaning wounds) was found on a shelf next to clean, unused medications. During an interview on 10/18/23, at 8:10 a.m. with the treatment nurse (LN 5), LN 5 verbalized, all medications and supplies taken from the storage room are never returned to the shelf to maintain sanitary (clean) condition. During an interview on 10/17/23 at 8:20 a.m. with the Director of Nurses (DON), the DON acknowledged the open bottle of hydrogen peroxide solution, and verbalized, once the medication is opened, it must be removed from 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 record review and interview, the facility failed to ensure a physician received notification of, or responded to, a resident's change of condition, for one of two sampled residents (Resident 1). This facility failure had the potential for Resident 1 to receive inadequate care and treatment, post an unwitnessed fall with injury. Findings: During a review of Resident 1's admission Record, dated 8/23, the admission Record indicated in part, Resident 1 was admitted to the facility on [DATE], and was discharged from the facility on 8/15/23. During a review of Resident 1's Progress Notes, dated 8/15/23, the Notes indicated in part, Resident (Resident 1) was in the dining room . the tab alarm beeped a couple times . turned around quickly and found resident (Resident 1) lying on left side . Resident 1 had laceration on left eyebrow, that was bleeding . MD was notified. During an interview on 8/31/23 at 12:37 p.m. with Licensed Nurse (LN 2) and the Director of Nursing (DON 1), LN 2 verbalized sending 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 interview and record review, the facility failed to maintain a complete medical record for 1 of 2 sampled residents (Resident 1) when monitoring of ordered Oxygen saturation (the amount of oxygen that's circulating in your blood) was not consistently documented in Resident 1 ' s Health Record. This failure had the potential for Resident 1 to not receive timely treatment if the oxygen saturation was low and for the resident to sustain complications. Findings: During a review of the facility ' s policy and procedure (P&P) titled, Charting and Documentation, dated December 2022, the P&P indicated, The following information are examples of documentation that may be included in the resident medical record .C. Treatments or services performed . During a review of Resident 1 ' s Order Summary Report, dated 6/21/23, the order indicated, to monitor pulse oximetry q shift (check and record the oxygen level every shift) with order start date of 1/24/23. During a review of Resident 1 ' s Electronic Health Record (EHR), dated 2/23 through 7/23, the EHR indicated, the facility staff 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.