Shoreline Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to transcribe and implement an x-ray as ordered by the physician in one out of three sampled residents (Resident 1) after Resident 1 sustained a fall.This failure resulted in a delay of treatment and care of a right hip fracture for Resident 1 that went unnoticed and untreated by the facility for 7 days. During a review of Resident 1's admission Record (AR) undated, the AR indicated Resident 1 was initially admitted to the facility on [DATE] with diagnoses including Anemia (condition where the body does not have enough healthy red blood cells), Dementia (a progressive state of decline in mental abilities), Depression (mood disorder that causes a persistent feeling of sadness and loss of interest), and Anxiety (mental health condition characterized by excessive worry, fear, and nervousness).During a review of Resident 1's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 9/19/25, Section C indicated a brief 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.

Based on interview and record review, the facility failed to ensure care and services provided met professional standards and principles for one of two residents (Resident 1) when mild swelling was observed on Resident 1's left hip five days after the fall incident which was not documented or monitored.This failure had the potential to result in Resident 1's care being compromised without the appropriate nursing follow-up monitoring and documentation in place.Findings:According to ANA's (American Nurses' Association) book titled, Principles for Nursing Documentation (Guidance for Registered Nurses), copyright 2010, the guidance indicated, in part, Clear, accurate, and accessible documentation is an essential element of safe, quality, evidence-based nursing practice. Documentation of nurses' work is critical as well for effective communication with each other and with other disciplines .Nurses document their work and outcomes for a number of reasons: the most important is for communicating within the health care team and providing information for other professionals .to support the…

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

Based on interview and record review, the facility failed to ensure physician's order to monitor the respiratory rate (RR - the number of breaths per minute) was followed for one of two residents (Resident 1) prior to administration of morphine sulfate (a highly controlled substance given for severe pain). This deficient practice had the potential to cause serious side effects including respiratory depression (slow, shallow, difficulty breathing).Findings:During a review of the facility's policy and procedure (P&P) titled, Medication Administration General Guidelines, undated, the P&P indicated in part, .B. Administration.2. Medications are administered in accordance with written orders of the attending physician.During a review of Resident 1's clinical record, Resident 1 was admitted to the facility under hospice care with the diagnosis of Vascular dementia (decline in thinking, memory and reasoning caused by damaged blood vessels), anemia (a blood condition), physical debility (physical general weakness) and COPD (lung disease).During a review of Resident 1's current Order Summary…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS - a standardized assessment and care-screening tool) accurately reflected the behavior status of one of two sampled residents (Resident 1). This failure had the potential to negatively affect Resident 1's plan of care and delivery of necessary care and services.During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted on [DATE], with diagnoses that include Alzheimer's disease (disease characterized by a progressive decline in mental abilities), psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 1's Order Summary Report (OSR), dated 8/28/25, the OSR indicated Quetiapine Fumarate (antipsychotic medication used to improve mood, thoughts, and behaviors) tablet 25 mg(milligrams) by mouth two…

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

Based on interview and record review, the facility failed to readmit one of three sampled residents (Resident 1) after the resident was transferred to the veteran VA hospital for medication evaluation and adjustment.The facility's failure placed Resident 1 at risk of being admitted to another facility which is far from the wife's residence therefore unable to visit frequently.A complaint was received by the California Department of Public Health (CDPH) on 7/14/25 alleging that Resident 1 had been transferred to an acute care hospital for medication evaluation and adjustment. According to the information provided, a representative of the resident was informed by facility staff that the resident's bed would be held and that the resident would be readmitted to the facility following hospitalization. However, the facility subsequently declined to readmit the resident upon discharge from the hospital.During an interview on 7/14/25 at 12:15 p.m., with Resident 1's responsible person (RP - person who makes healthcare decisions for a patient who is unable), the RP reported that the facility…

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

Based on interview and record review, the facility failed to:1. Ensure two of three sampled residents (Resident 1 and 2) were provided with a written bed-hold notification upon transfer to general acute care hospitals. 2. Ensure Resident 1's wife was provided with the bed hold private payment information before the resident was transferred to the veteran (VA) emergency department (ED).These failures resulted in the residents not having a bed-hold and were at risk of not being able to return to the facility.1. A review of the facility's policy and procedure titled Admission, Transfer, Discharge and Bed-Holds, dated 12/2016, indicated Upon transfer or discharge, a notice of transfer and discharge, as well as the bed-hold notification will be completed and given to the resident at the time of transfer or discharge or as soon as practicable. In the BED HOLD and readmission section of the policy indicated the facility will notify the resident or resident representative at the time of admission and again prior to hospital transfer or therapeutic leave, of the bed hold and readmissions…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 sampled resident (Resident 2) was protected from physical and verbal abuse from a fellow resident (Resident 1) who was having undirected behavioral symptoms and outbursts. This facility failure resulted in Resident 2 being slapped by Resident 1 and sustaining bruises (purplish/reddish skin discoloration) to the left arm and hand. Findings: During a review of Resident 2's admission Record (AR), the AR indicated, Resident 2 had diagnoses including, chronic obstructive pulmonary disease (lung disease that makes breathing difficult), acute and chronic respiratory failure with hypoxia (low oxygen levels in the blood), anxiety disorder (excessive feelings of worry, fear, and unease that significantly interfere with daily life), and depression (feeling of sadness, hopelessness, and loss of interest in activities previously enjoyed). During a review of Resident 2's Situation, Background, Assessment, Recommendation (SBAR), dated 5/24/25, the SBAR indicated, around 1 a.m. Resident 2 was slapped by another…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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's Interdisciplinary Team (IDT - a group of medical staff that work together to provide care of residents) failed to initiate a Significant Change in Status Assessment (SCSA - a comprehensive assessment) for one of four sampled residents (Resident 1) when: 1. Resident 1 refused to take schizophrenia (mental disorder that affects how a person thinks, feels, and behaves), depression (persistent feelings of sadness that interfere with daily life) and other medications. As a result, Resident 1 developed severe symptoms of distress including psychosis (loss of touched with reality), delusions, hallucinations, and paranoia. 2. Resident 1 showed physical and verbal aggression towards other residents and staff, and refused to follow the facility's smoking rules. These failures resulted in Resident 1's escalating behavior becoming more erratic, with increased aggressiveness toward others. No appropriate clinical interventions were implemented, which placed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1), had their health status accurately documented on the admission Minimum Data Set (MDS: a comprehensive assessment that helps nursing home staff identify health problems and track the improvement or decline of those problems). This failure had the potential to result in an inaccurate plan of care, compromising the resident's quality of life and leading to unmet needs, inappropriate interventions, and negative health outcomes. Findings: During a review of Resident 1's admission Record (AR), the AR indicated, Resident 1 was admitted on [DATE] with diagnoses that included, fracture of right and left calcaneus (breaks in both heel bones), psychosis (loss of contact with reality, symptoms of hallucinations delusions and disorganized thinking), unspecified schizophrenia (psychotic symptoms that do not meet the criteria for a more specific schizophrenia spectrum or other psychotic disorder), chronic pain,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 develop and implement a comprehensive, person-centered care plan (a plan that includes clear goals to meet a resident's needs) when: 1. Female staff were not consistently assigned to Resident 1 as care planned. This failure had the potential to cause emotional distress and compromise Resident 1's psychosocial well-being. 2. Resident 1's cam boot (foot/ankle brace) was replaced with a non-weight-bearing immobilizer cast (a stiff wrap that keeps an injured area stable) on the left foot with no protocol in place for care. This failure had the potential to result in poor circulatory function and delayed healing of Resident 1's left foot fracture. Findings: During a review of Resident 1's admission Record (AR), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses including, psychosis (loss of contact with reality, hallucinations, delusions and disorganized thinking) and unspecified schizophrenia (mental disorder characterized…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 infection control practices in one of two sampled residents (Resident 2) when Resident 2's respiratory care equipment was not stored in a manner to prevent cross-contamination (accidentally transferring harmful bacteria) or labeled/dated. These facility failures had the potential to result in cross-contamination that could negatively impact Resident 2's health and safety and cause preventable HAIs (Healthcare Associated Infections). Findings: During a review of Resident 2's admission Record (AR), the AR indicated, Resident 2 had diagnoses including, chronic obstructive pulmonary disease (lung disease that makes breathing difficult), acute and chronic respiratory failure with hypoxia (low oxygen levels in the blood), anxiety disorder (excessive feelings of worry, fear, and unease that significantly interfere with daily life), and depression (feelings of sadness, hopelessness, and loss of interest in activities previously enjoyed). During an observation on 6/2/25 at 5:18 p.m. inside Resident 2's room, a…

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

Based on observation, interview, and record review, the facility failed to ensure the facility's South Side dining room was safe and clean as evidenced by: 1. A wet and dirty plastic container, surrounded by flying insects (fruit flies), was underneath the sink while ten residents were inside the dining room eating lunch. 2. Next to the sink was a trash can surrounded by flying insects (flies). 3. The corner next to the sink was dirty and the walls had food particles adhered to the wall. 4. The sink had been nonfunctional since 6/1/25, was not covered and without any signage indicating the sink was not working. 5. The dining room floor has broken tiles in multiple areas. 6. The dining room had lots of dark stains especially around the corners. These facility failures exposed residents to risks of contamination, cross-contamination, illness, infection, and injuries from tripping and falling. Findings: 1. A review of the facility's policy and procedure titled Safe, Clean, Comfortable, and Home like Environment, dated 6/2023, indicates In accordance with Residents Rights, the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report a resident's fall incident with fracture to the Department for one of two residents (Resident 1). Resident 1 experienced an unwitnessed fall, complained of pain on the left hip with an X-ray (process of imaging, using radiation) that indicated an acute fracture. This failure delayed the Department's investigation into the incident and had the potential for Resident 1 and other residents to experience a decline in safety, comfort, and overall well-being. Findings: On 5/16/25, an unannounced visit was made to the facility to investigate a complaint regarding a resident's unwitnessed fall. During a review of Resident 1's admission Record, this indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included dementia (a group of thinking and social symptoms that interferes with daily functioning) and fracture in the right femur (break in the right leg bone). A review of the Minimum Data Set (MDS - a standardized 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.

Based on interview and record review, the facility failed to change a hearing aid filter for one of three sampled residents (Resident 1) per instructions from an outside clinic. This failure had the potential for Resident 1's hearing aid to be less effective, potentially impacting Resident 1's ability to hear and communicate. Findings: During a concurrent interview and record review, on 4/16/25, beginning at 3:30 p.m., with the Health Information Manager (HIM 1) and Assistant Director of Nursing (ADON 1), Resident 1's medical record was reviewed. Resident 1 had an appointment at an outpatient clinic on 2/27/25, where Resident 1 returned to the facility with new hearing aids. The outside clinic provided instructions to change the hearing aid filter once a month. The HIM 1 and ADON 1 verbalized Resident 1's hearing aid filter should have been changed on 3/27/25, but it did not happen until 4/8/25. The ADON 1 verbalized the facility could not provide documentation indicating when it received Resident 1's office visit summary with care instructions for Resident 1's 2/27/25 outpatient…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 scabies (a contagious skin disease marked by itching and small raised red spots, caused by mites) protocol for one of three sampled Residents (Resident 1). This failure had the potential for scabies to spread throughout the facility. Findings: During a concurrent interview and record review, on 4/17/25, at 1:50 p.m., with the Assistant Director of Nursing (ADON 1), Resident 1's medical record was reviewed. Resident 1's medical record indicated Resident 1 was seen by a Dermatologist (a medical practitioner specializing in the diagnosis and treatment of skin disorders) on 4/4/25, where Resident 1 was suspected to have scabies. Resident 1 was prescribed Permethrin 5% cream (a medication commonly used to treat scabies). The ADON 1 verbalized the facility could not provide documentation indicating it placed Resident 1 on enhanced barrier precautions on 4/4/25, upon return to the facility, when Resident 1 was suspected of having scabies. During a concurrent interview and record review, on 4/17/25, at 2:48 p.m., with…

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

Based on interview and record review, the facility failed to follow physician orders for the administration of insulin for one of two sampled residents (Resident 1). This facility failure had the potential to expose Resident 1 to unsafe insulin doses, and preventable medication errors. Findings: During a concurrent record review and interview, on 3/12/25, beginning at 3:10 p.m., with the Director of Nursing (DON 1) and Health Information Manager (HIM 1), Resident 1's Medication Administration Record (MAR) was reviewed. Resident 1 had an order for Novolog (a fast acting insulin) 100 unit/ml(milliliter) FLEXPEN (a device used to deliver the insulin) inject as per sliding scale .BS (blood sugar) more than 401 give 16 units and call MD. On 1/25/25, Resident 1's blood sugar was 481. Resident 1's Progress Notes indicated a nurse administered only 14 units of insulin and called the MD. The DON 1 and HIM 1 verbalized the nurse administered the incorrect amount of insulin. The DON 1 and HIM 1 could not provide documentation indicating Resident 1's physician acknowledged the nurses…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide quality care for one of two sampled residents (Resident 1) when: 1. Numerous medications were not administered to Resident 1, due to Resident 1 being offsite at a dialysis center. 2. Physical therapy sessions were not provided to Resident 1 as ordered. 3. There was a facility delay following physician orders for Resident 1 to begin weight bearing physical therapy. These facility failures had the potential to result in negative outcomes for Resident 1 and for a delay in care. Findings: 1. During a review of Resident 1's admission Record undated, indicated in part, Resident 1 was admitted to the facility on [DATE], with diagnoses including end stage renal disease (a severe condition where the kidneys permanently lose their ability to function properly) type two diabetes (a disease in which blood sugar levels are to high) and dependence on renal dialysis (a life sustaining treatment that filters blood when kidneys fail to remove waste end excess…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintain complete and accurate medical records for one of two sampled residents (Resident 1) when an interdisciplinary team (IDT- team members from different discipline with common purpose, to set goals, share responsibilities and make decisions together) admission assessment form was incomplete. This failure had the potential for Resident 1 to have inaccurate and incomplete medical records which could affect the care being provided to them. Findings: During a review of Resident 1's admission Record (AR), dated 2/28/25, the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that include COVID-19 (contagious viral infection that affects breathing) and Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities). During a concurrent interview and record review on 2/28/25 at 12:10 p.m. with the Director of Nursing (DON), Resident 1's IDT admission Assessment, dated 2/18/25 was reviewed. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately complete a Minimum Data Set (MDS) Assessment (an assessment tool) for one of two residents (Resident 1). As a result, the elopement risk assessment did not accurately reflect Resident 1's status. Findings: A review of Resident 1's face sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including unspecified dementia (signifies memory loss, impaired thinking). During the interview on 2/28/25 at 1:45 p.m., with a Certified Nurse Assistant (CNA2), CNA2 stated there was an instance in January 2025 when Resident 1 went outside the main entrance door in South station by following a visitor who was going out when the door opened. CNA2 reported the incident to charge nurse. During a review of Resident1's Medication Administration Record (MAR) dated February 2025, under behavior monitoring, this indicated two episodes of anxiety (one episode on 2/4 and another on 2/6), and one episode of paranoia (suspiciousness) on 2/2.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure interventions of a behavioral care plan was implemented for one of two residents (Resident 1). This failure resulted in increased behavioral episodes of aggression, anxiety and paranoia (suspiciousness) for Resident 1. Findings: A review of the facility's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including unspecified dementia (signifies memory loss, impaired thinking). A review of Resident1's initial psychiatric evaluation by a practitioner dated 8/8/25, this indicated Resident1 was in the hospital due to code 5150 (danger to self and others), struck another resident on admission day, was easily agitated, and was given 1:1 care (1 staff assigned solely to Resident1). A review or Resident 1's care plan dated 8/6/24, indicated focused care on anxiety manifested by aggressiveness or wandering/pacing agitated behavior, and poor impulse control with the goals of reducing anxiety, to keep self and…

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

Based on observation, interview, and record review, the facility failed to maintain a clean and homelike environment in two shower rooms. These facility failures had the potential to negatively impact residents. Findings: During a concurrent observation and interview, on 1/28/25, starting at 4:41 p.m., with the Health Information Manager (HIM 1), the facility's shower rooms were observed. Inside shower room one, located in the south wing of the facility, eight clean/unused razers were found on top of a dirty sharp's container. Inside shower room two, located in the south wing of the facility, seven clean/unused razers were found on top of the dirty sharp's container. The HIM 1 verbalized the clean/unused razers should have been stored at the nurse's station, inside a cabinet, and not on top of the dirty sharp's containers in both shower rooms. Shower room two, located in the south side of the facility along with shower room two, located in the central wing of the facility had broken floor tiles. The HIM 1 confirmed the broken floor tiles in both the south and central wings shower…

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

Based on observation, interview, and facility policy review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, the facility's kitchen staff failed to maintain clean food preparation equipment, date and label leftovers, thaw raw meat properly, wear gloves when handling ready-to-eat (RTE) food, and ensure hair restraints were worn in the food preparation areas. This deficient practice had the potential to affect all residents who received food from the kitchen. Findings included: 1. A facility policy titled, Kitchen Sanitation & [and] Cleaning Schedules, effective in February 2009, indicated 2.0 POLICY Maintain a clean, sanitary, and safe kitchen. The policy indicated, 3.0 PROCEDURE 1. The Food and Dining Services Manager develops, implements, and monitors a cleaning schedule that assigns specific cleaning responsibilities to specific individuals. The policy further indicated, The Food and Dining Services Manager/designee will check the cleaning schedule at the end of each shift to assure…

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

Based on observation, interview, and facility policy review, the facility failed to dispose of garbage and refuse properly affecting 3 of 3 dumpsters. Specifically, the trash and recycle dumpster lids were open with overflowing trash piled up over the top of the dumpsters and trash and debris was on the ground surrounding the base of the dumpsters. This had the potential to affect all 171 residents who resided in the facility at the time of the survey. Findings included: A facility policy titled, Garbage & Rubbish Disposal, effective in February 2009, indicated, 1.0 PURPOSE Maintain a sanitary and safe environment through effective disposal of garbage and rubbish. The policy indicated the section titled 3.0 PROCEDURE included 8. Outside dumpsters provided by garbage pickup services must be kept closed and free of litter around the dumpster area. During a concurrent observation and interview on 01/13/2025 at 9:15 AM, one recycle dumpster was observed with both lids open and one trash dumpster with one of two lids open with overflowing trash piled up over the top of the dumpster. 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, interview, and facility policy review, the facility failed to protect the residents' right to be free from physical abuse by a resident during 4 (10/28/2024, 12/15/2024, 12/19/2024, and 01/12/2025) of 4 incidents of resident-to-resident abuse involving Resident #118. Findings included: A facility policy titled, Alleged or Suspected Abuse and Crime Reporting, revised 10/2022, indicated, Each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The policy further indicated, The facility will monitor the adequacy of assessment, care planning and monitoring of residents with needs or behaviors that may likely lead to conflict, altercation, abuse, neglect, exploitation and misappropriation and mistreatment such as, which included, Physically aggressive or self-injurious behaviors. Resident #118's admission Record indicated the facility admitted the resident on 08/02/2024. According to the admission Record, the resident had a medical history that included diagnoses of dementia, psychosis, and anxiety…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, record review, facility policy review, and review of the California Department of Health Care Services Preadmission Screening and Resident Review (PASRR) Level I Assessment Guide, the facility failed to ensure Level I PASRR screenings were accurate and also failed to submit a new Level I PASRR screening after a resident remained in the facility longer than 30 days, during which they were exempt from the requirement. The deficiencies affected 3 (Residents #26, #103, and #129) of 4 residents reviewed for PASRR requirements. Findings included: A facility policy titled, Resident Assessment-Coordination with PASARR [Preadmission Screening and Resident Review; PASRR] Program, reviewed/revised 05/2024, revealed, This facility coordinates assessments with the preadmission screening and Resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. The policy revealed, 1. Applicants to this facility will…

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

Based on observation, interview, and facility document and policy review, the facility failed to serve meals according to the recipes for the planned menu for residents prescribed a pureed diet. Specifically, staff pureed plain beef instead of beef stew, mixed breadcrumbs in water in place of sliced bread to make pureed bread and served applesauce in place of pureed baked apple slices to residents on a pureed diet. This deficient practice had the potential to affect 22 residents who received pureed diets. Findings included: A facility policy titled, Menus, effective February 2009, indicated, 1.0 PURPOSE To ensure food variety, adequate nutrition, and allow for effective planning of food and dining service. The policy indicated the section titled 2.0 FUNDAMENTAL INFORMATION included 3. Therapeutic (Special) diet descriptions/extensions are written for physician-ordered special diets. The policy further indicated the section titled 4.0 PROCEDURE included 6. Recipes are available for use and will be utilized. A facility policy titled, Therapeutic Diets, effective February 2009,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 obtain a physician order, prior to providing one of two sampled residents (Resident 1) with psychological services. This failure had the potential for Resident 1 to receive services not approved by a physician. Findings: During a concurrent record review and interview, on 9/17/24, starting at 11:01 a.m., with the Health Information Manager (HIM 1) Resident 1 ' s medical record was reviewed. When asked if Resident 1 was receiving psychological services while at the facility, the HIM 1 verbalzied yes. Resident 1 ' s medical record indicated Resident 1 had received psychological services from 11/1/23 to 7/17/24. The HIM 1 could not provide documentation indicating Resident 1 ' s physician had written an order for Resident 1 to receive psychological services. During an interview on 9/19/24, at 1:48 p.m., with the Director of Nursing (DON 1), the DON 1 verbalzied the facility could not provide documentation indicating Resident 1 ' s physician had written and order for psychological services. During a review of the facility ' s…

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

Based on record review and interview, the facility failed to ensure physician orders for wound care treatment were followed, for one of two sampled Residents (Resident 1). This failure had the potential for Resident 1 to experience complications from worsening pressure ulcers including increased pain and wound infections. Findings: During a review of Resident 1's admission Record undated, the admission Record indicated in part, Resident 1 had diagnoses including a pressure ulcer (an injury that breaks down the skin and underlying tissue) of the sacral region (lower back area), which was unstageable (full thickness tissue loss), Type Two Diabetes (a chronic condition that causes high blood glucose levels in the blood, which in turn, can delay and/or complicate wound healing), and abnormalities of gait (walking) and mobility (movement). During a concurrent record review and interview, on 8/20/24, starting at 2:00 p.m., with the Health Information Manger (HIM 1), Resident 1's medical record was reviewed. Resident 1's Order Details undated, indicated in part, Resident 1's physician on…

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

Based on interview and record review, the facility failed to reorder medication from the pharmacy according to their policy and procedure, for one of three sampled residents (Resident 1). This failure had the potential to trigger seizures (sudden, uncontrolled burst of electrical activity in brain that can cause temporary changes in behavior, movement, feelings, and level of consciousness) to Resident 1 that can lead to fall or other serious injuries. Findings: During a review of medical records (admission, assessments, history and physical), indicated Resident 1 was admitted in the facility on 4/24/24 with diagnosis of other seizures. BIMS (Brief Interview for Mental Status- a tool used to screen and identify cognitive condition of residents upon admission into a long-term care facility) score of 15 indicated Resident 1 has an intact cognition. Per history and physical as indicated in the order summary, physician determines Resident 1 has the mental capacity to make healthcare decisions. Order summary indicated Resident 1 has an order for Lacosamide (medication to treat partial…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident room and restroom, in a clean and homelike manner. This failure had the potential to negatively impact residents. Findings: During a concurrent observation, and interview, on 6/20/24, starting at 3:30 p.m., with the Maintenance Director (MTD 1), Resident 2's room was toured. Inside Resident 2's room, the wall was observed in multiple places, to be in a state of disrepair, with large scrapes and areas of missing paint. Inside Resident 2's restroom, a hand sanitizing dispenser, located above the sink, was missing a front cover. The MTD 1 verbalized the wall would need to be repaired and a front cover would need to be installed on the hand sanitizing dispenser. The MTD 1 confirmed these environmental concerns had not been reported by staff nor were these environmental concerns listed on the maintenance log, as items that needed to be addressed. During a review of the facility's policy and procedure titled Resident Environmental Quality dated 10/22, indicated in part It is the policy of this…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 assess and revise the care plan for one of three sampled residents (Resident 1) after a verbal altercation with another resident. This failure had the potential to cause psychosocial harm to Resident 1. Findings: Resident 1 was admitted to Shoreline Care Center on 2/28/24, with a primary diagnosis of Unspecified Intracranial Injury (trauma to the head) with Loss of Consciousness. A Minimum Data Set (MDS) cognitive assessment tool reveals Resident 1 of having Brief Interview of Mental Status (BIMS) score 09 (moderately impaired cognition), indicating a mental capacity for an interview. During a concurrent observation and interview on 3/13/24 at 2:30 p.m. at room [ROOM NUMBER], Resident 1 was observed laying in her bed, calm and cooperative, call lights within reach. Resident 1 stated that she became nauseous (urge to vomit), anxious (experiencing worry, unease, or nervousness), and unable to sleep for few nights after the incident last…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide adequate supervision for one of two sampled residents (Resident 1), when Resident 1 eloped (a situation where a resident leaves the facility, without the knowledge of the staff) on two separate occasions. This facility failure had the potential for Resident 1 to suffer negative outcomes. Findings: During a review of Resident 1 ' s admission Record undated, indicated in part, Resident 1 was admitted to the facility on [DATE], with diagnoses including psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality) stimulant dependence (a condition where a person misuses certain drugs or medications to the point that it has negative effects on their life), post-traumatic stress disorder (a psychiatric disorder that may occur in people who have experienced or witnessed a traumatic event, series of events, or set of circumstances), and history of traumatic brain injury (an injury that affects how the…

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

Based on observation, interview and record review, the facility failed to ensure licensed nurses (LNs) were competent in providing quality of care for two of 2 sampled residents when they failed to: 1. Complete a comprehensive assessment and individualized care plan related to Resident 1's change of condition (COC), did not report to the attending physician after monitoring the COC for possible further instructions and/or orders. 2. Notify the responsible party on an open lesion documented by LN3 on admission. These failures had the potential for delayed identification of change in health status and implementation of needed healthcare interventions. Findings: 1. During a review of Resident 1's admission Record, dated 11/09/23, this indicated in part that Resident 1 was admitted to the facility with diagnoses that included acute osteomyelitis, venous insufficiency, localized edema, diabetes mellitus (DM) type 2 without complications. During a review of Resident 1's Initial Evaluation, History and Physical Examination dated 11/09/23, Resident 1 has a significant history of seizure…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain resident rooms in a clean and homelike environment when: 1. Broken floor tiles observed in two resident rooms. 2. An electrical fan was covered in dust/debris. These facility failures had the potential to negatively impact residents. Findings: During a concurrent observation and interview, on 11/9/23, at 12:12 p.m. with the maintenance director (MTD 1), room [ROOM NUMBER] and room [ROOM NUMBER]'s floors were observed with broken floor tiles. The MTD 1 confirmed both rooms had a broken floor tile and verbalized they needed to be replaced. During a concurrent observation and interview, on 11/9/23, at 12:22 p.m. with MTD 1, in room [ROOM NUMBER], an electrical fan was covered in dust/debris. The MTD 1 acknowledged the electrical fan was dirty and it needed to be cleaned. During a review of the facility's policy and procedure titled Safe and Homelike Environment dated 2/5/20, indicated in part Housekeeping and maintenance services…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain a bed remote control and call light in safe operating conditions. These facility failures had the potential for equipment to be unsafe for use. Findings: During a concurrent observation and interview, on 11/9/23, at 12:06 p.m. with the maintenance director (MTD 1), in room [ROOM NUMBER], a bed remote control and call light were observed with exposed wiring. The MTD 1 confirmed the exposed wiring on the bed remote control and call light and verbalized both needed to be replaced. During a review of the facility's policy and procedure titled Resident Rights, dated 10/22, indicated in part The resident has a right to a safe, clean, comfortable, and homelike environment.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a handrail was in good working order. This facility failure had the potential to place a resident at risk for an avoidable accident. Findings: During a concurrent observation and interview, on 11/9/23, at 12:28 p.m. with the maintenance director (MTD 1), outside room [ROOM NUMBER], a handrail was observed in a state of disrepair and not securely fastened to the wall. The MTD 1 verbalized being unaware of the issue and further verbalized the broken handrail would need to be fixed/replaced. During a review of the facility's policy and procedure titled Resident Rights, dated 10/22, indicated in part Report any unresolved environmental concerns to the Administrator, The policy further indicated The resident has a right to a safe, clean, comfortable, and homelike environment.

Based on observation and interview, the facility failed to ensure residents and unauthorized personnel had no access to an open, unlocked supply delivery door. This failure had the potential for residents to go out of the facility unnoticed, into a busy street causing safety issues or for an unauthorized person to enter the facility unnoticed, placing the welfare and safety of residents and staff at risk. Findings: During a facility tour on 9/14/23 at 11:20 AM, a door next to the facility's locked unit (station for residents with memory loss and wandering behavior) marked For deliveries, was observed to be unlocked, with easy access in and out of the facility to a busy street. During a concurrent observation and interview on 9/14/23 at 11:40 AM with a licensed nurse (LN1), the delivery door was observed unlocked. LN1 acknowledged the delivery door was open and unlocked, and indicated the door should always be closed and locked. During a review of the facility policy and procedure (P&P) titled, Instructions. Door, Locks and Alarms, dated 6/2/2023, the P&P indicated, Test doors 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 record review and interview, the facility failed to provide showers for one of two sampled residents (Resident 1) who required assistance with activities of daily living (ADL). This failure resulted in Resident 1's grooming and personal hygiene not maintained and had a potential to affect Resident 1's quality of life. Findings: During a review of Resident 1's clinical records (CR), this indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including but not limited to multiple fractures of left side ribs, difficulty in walking, and generalized muscle weakness. The admission Minimum Data Set (MDS-an assessment tool) dated 08/10/23, indicated Resident 1 was cognitively intact and required extensive assistance with bathing. During a concurrent record review and interview, on 9/21/23 starting at 11:44 A.M., the bathing record for Resident 1 was reviewed and discussed with the director of nursing (DON); the bathing (ADL documentation) record indicated from 8/11/23 to 8/19/23, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of two residents (Resident 1) was seen by the physician every 30 days for the first 90 days after admission as stipulated in the regulation. This failure resulted in Resident 1 not able to discuss and not offered to participate in his treatment plans. Findings: During a review of Resident 1's clinical records (CR), this indicated Resident 1 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS-an assessment tool) dated, 08/10/23 indicated Resident 1 is cognitively intact. During a concurrent record review and interview, on 9/21/23 at 1:40 P.M., the record titled, Physician Visit for Resident 1 was reviewed and discussed with the director of nursing (DON); the History and Physical record indicated the physician handwrote the physical assessment for Resident 1 on 8/4/23. However, the next physician visit did not occur until 48 days later after the first visit as evidenced in the physician's progress note dated, 9/21/23…

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 record review and interview, the facility failed to demonstrate it offered or provided a shower/bath, for one of two sampled residents (Resident 1). This facility failure had the potential for Resident 1 to experience negative skin outcomes. Findings: During a concurrent interview and record review on 8/23/23, starting at 2:00 p.m., with the Director of Nursing (DON 1) and the Health Information Manager (HIM 1), Resident 1's medical record was reviewed. The DON 1 and HIM 1 confirmed Resident 1's shower schedule was every Monday and Thursday. Resident 1's Documentation Survey Report (a form used by certified nursing assistants to document ADL care) dated 7/23, indicated on Monday 7/17/23 and Thursday 7/20/23, Resident 1 did not receive a shower or bath. The DON 1 and HIM 1 confirmed Resident 1 was at the facility on those dates and acknowledged facility documentation indicated Resident 1 did not receive a shower or bath, while at the facility. The DON 1 and HIM 1 further acknowledged there was no documentation indicating Resident 1 had refused to receive a shower or bath…

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

Based on observation, interview, and record review, the facility failed to ensure: 1. The temperature was monitored in the dry food storage room; 2. The ice machine's preventative maintenance (PMs) and cleaning schedule was performed and documented according to the manufacturer's instruction for use (MIFU's) manual; 3. The ice machine floor drain was clean, free of debris, and trash. These failures had the potential to place residents at risk for developing foodborne illness. Findings: 1. During an observation on 6/14/22, at 9:20 a.m., in the dieticians office, the office was observed to also be used as the dry food storage room. The room was divided by a caged wall. One side of the room was the office, and the other side was food storage. The food was stored on shelves. The room felt warm and not well ventilated and no thermometer was seen. During a concurrent observation and interview, on 6/15/22, at 3:30 p.m., with the dietary supervisor (DS), in the dry food storage room, it was observed there was a thermometer hanging on the wall behind the door. The thermometer was reading…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain a safe, sanitary, and homelike environment when: 1. A wall was in a state of disrepair in room six. 2. The floor was in disrepair in room two. 3. Missing section of handrail in the north wing of the facility. 4. Ill fitting closet drawer in room five. 5. Used equipment were stored outside the building of the south wing in view of the residents, staff, and visitors. 6. A toilet seat was in disrepair and peeling paint was on the door jams in room [ROOM NUMBER]. 7. A wall behind the bathroom sink was in disrepair, a faucet knob was not in good working order, limescale buildup was on the faucet, and a vent cover was missing on the bathroom ceiling in room [ROOM NUMBER]. 8. Two rooms with torn loose wall paper, stripped down to the dry wall. These facility failures had the potential to negatively effect residents' safety and wellbeing. Findings: 1. During an observation on 6/14/22, at 11:00 a.m., in room six, a section of wall,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain infection control practices when: 1. Hand hygiene was not performed in the kitchen. 2. Oxygen tubing and face mask connected to a Nebulizer (breathing treatment machine) was not dated and stored in a plastic bag for one resident (Resident 78). 3. Residents' shared bathrooms (rooms 23, 24 and 25, 26) had unlabeled and uncovered resident supplies, (large basins, bedpan, and emesis basin [small container used to collect vomit]) and were stored on the floor next to the toilet. These facility failures had the potential to result in food borne illness, cross-contamination (the transfer of harmful bacteria) of resident equipment and supplies that could impact residents' health and safety. Findings: 1. During a review of the facility's policy and procedure (P&P) titled, Dietary Services, dated 2/12, the P&P indicated in part, .To prevent contamination of food products and therefore prevent foodborne illness .Personal Hygiene: D. Adequate…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the indwelling catheter (tube draining urine from bladder) collection bag was covered with a dignity bag (covering for collection bag), for one unsampled resident (Resident 68). This facility failure had the potential for the Resident 68 to be embarrassed and thus, affect their psychosocial well being. Finding: During an observation on 6/14/22, at 10:11 a.m., Resident 68 was observed in their room, lying in bed, with eyes closed. Resident 68's indwelling urinary catheter's collection bag was hanging below the bed. The collection bag did not have a dignity bag cover. During an interview on 6/14/22, at 10:15 a.m., the licensed nurse (LN 2) acknowledged the indwelling urinary catheter collection bag did not have a dignity bag cover. During an interview on 6/17/22, at 3:46 p.m., the director of nursing (DON) indicated, the facility does not have a policy and procedure regarding a dignity bag, but it is the facility's practice to place a dignity bag to cover on the indwelling urinary catheter collection bag.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the resident call light (button to press if a resident needs help or assistance) was within reach for two of 32 sampled residents (Resident 13 and Resident 102). This facility failure had the potential for the residents to not be able to call for help or assistance as needed. Findings: During a concurrent observation and interview on 6/14/22, at 10:34 a.m., in Resident 13's room, Resident 13's living area was observed with a Licensed Nurse (LN 2). Resident 13's call light was observed on the floor, under the bed. LN 2 acknowledged, the call light button was on the floor. During an observation on 6/17/22, at 10:30 a.m., in room [ROOM NUMBER] C, the call light for Resident 102 was laying on the floor. During an interview on 6/17/22, at 10:34 a.m., in room [ROOM NUMBER] C, a Certified Nurse Assistant (CNA 1) acknowledged, Resident 102's call light was on the floor. During a review of the facility's policies and procedure (P&P) titled,…

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

Based on observation, interview, and record review, the facility failed to ensure a care plan intervention for oxygen use was being followed for one of 32 sampled residents (Resident 40). This failure had the potential to result in a decline in Resident 40's physical well being. Findings: During an observation on 06/14/2022, beginning at 10:45 a.m., in Resident 40's room, the oxygen concentrator was set at 4 liters via nasal cannula (oxygen tube placed in nose). During an interview, on 06/14/2022, beginning at 10:45 a.m., with Resident 40, Resident 40 stated, It's always been at 4 liters. During a concurrent interview and record review, on 6/14/2022, at 10:48 a.m., with Licensed Nurse 1 (LN 1), Resident 40's physician order for oxygen administration, dated 9/25/2021, indicated Oxygen at 2 liters per minute via nasal cannula continuously. LN 1 confirmed, that oxygen concentrator was set at 4 liters per minute. LN 1 stated, Oh no, it needs to be changed to 2 liters. During a review of Resident 40's Care Plan for Respiratory Illness (COPD), dated 9/26/2021,the Care Plan indicated 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 record review and interview, the facility failed to implement Physician's orders for weekly weights and notify the Physician of significant weight loss, for one of 32 sampled residents (Resident 4). This failure had the potential to cause Resident 4 a further decline in health status. Findings: Review of [NAME] and [NAME], 7th Edition, Mosby's Fundamentals of Nursing, page 419 in the section titled, Legal Implications in Nursing Practice indicates, Nurses are obligated to follow physician order unless they believe they orders are in error or would harm clients. Review of [NAME] and [NAME], 7th Edition, Mosby's Fundamentals of Nursing, page 243 in the section titled, Data Documentation indicates, Observation and recording of client status is a legal and professional responsibility. The nurse practice acts in all states and the American Nurses Association Nursing's Social Policy Statement (2003) mandate, or require, accurate data collection and recording as independent functions essential to the role 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 and interview, the facility failed to ensure the posted nurse staffing information was current. This facility failure had the potential for residents and visitors to not to be aware of the actual nursing hours the facility is providing. Findings: During an observation of the facility's lobby on 6/15/22, at 10:35 a.m., the posted nurse staffing was dated 6/14/22. During an interview on 6/15/22, at 10:38 a.m., the director of nursing (DON) acknowledged the posted nurse staffing was not current. During an interview on 6/17/22 at 3:15 p.m., the DON indicated, the facility does not have a policy regarding posting of nurse staffing. The facility follows the federal regulation for nurse staffing postings.

Based on record review, and interview, the facility failed to ensure a physician's reason of no action/no change on the pharmacist's recommendation for Cymbalta (medication used to treat depression and anxiety) was documented in the resident's medical record in one of 32 sampled residents (Resident 105). This failure had the potential for over medication and /or ineffective medication administration. Findings: During a concurrent record review, and interview, on 6/17/22, at 2:59 p.m., with the director of nursing (DON 1), Resident 105's Consultation Report (a form used by pharmacists to make drug recommendations to physicians) was reviewed. The Consultation Report, dated 2/14/22, indicated in part, Resident 105 was taking Cymbalta 30 mg QD (every day) for depression. The report further indicated A GDR (gradual dose reduction) should be attempted in 2 separate quarters, with at least 1 month between attempts, within the first year in which an individual is admitted on a psychotropic medication or after the facility has initiated such medication, and then annually unless clinically…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 32 sampled residents (Resident 58's) Lorazepam (medication used for anxiety) ordered as needed (PRN) did not exceed 14 days of therapy unless renewed. This facility failure had the potential for Resident 58 to be over medicated or have no assessment for renewal use. Findings: During a review of the health record for Resident 58's on 6/16/22, at 12:12 p.m., the health record indicated orders for: 1. Lorazepam 0.5mg by mouth twice a day as needed for anxiety for 90 days, ordered on 2/15/22 2. Lorazepam 0.5mg by mouth twice a day as needed for anxiety for 120 days ordered on 5/25/22. During a concurrent interview and record review, on 6/16/22 at 12:41 p.m., with the nurse supervisor (RNSUP), Resident 58's health record was reviewed. Resident 58's pharmacy recommendation indicated, on 1/18/22 the pharmacist commented on Lorazepam as PRN (as necessary) order for anxiolytic, which has been greater for 14 days without a stop date. Pharmacy recommendation - please discontinue prn Lorazepam, tapering as necessary, if…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 have a standardized recipe for tuna salad, and no system in place to acknowledge food allergies. This facility failure had the potential to negatively impact the health and safety of residents with known food allergies. Findings: A review of the facility policy and procedure (P&P) titled, Resident Food Preferences, dated 2/09, indicated in part, .The food and dining services staff will avoid serving products that contribute to food allergies and make every attempt to meet the resident's food preferences. During an observation on 6/14/22, at 8:55 a.m., during a tour of the kitchen, in the walk- in refrigerator, a container of tuna salad was observed. The tuna salad container indicated it was made on 6/13/22 and use by date was 6/18/22. During an interview on 6/15/22, at 2:07 p.m., with the cook (Cook 2), [NAME] 2 was asked how tuna salad was made. [NAME] 2 verbalized, the tuna comes from a can that is taken from dry storage. [NAME] 2…

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

Based on observation, interview, and record review, the facility failed to follow the physician's prescribed therapeutic diet order for one of 32 sampled residents (Resident 78) during lunch on 6/16/22. This failure resulted in Resident 78 receiving the wrong prescribed lunch meal and had the potential to result in decreased food intake or unplanned weight loss, further compromising the nutritional and medical status of Resident 78. Findings: During a review of the facility's policy and procedure (P&P) titled, Therapeutic Diets, dated 2/09, the P&P indicated in part .Ensure therapeutic diets are written and available as ordered .therapeutic diets (also known as special diets) and mechanically-altered diets are ordered by the physician and planned by a registered dietician .the facility prepares and serves all special diets as planned. During an interview on 6/14/22, at 10:38 a.m., with Resident 78, Resident 78 stated, Food portions have become smaller. I am still hungry at the end of meals. Resident 78 verbalized, the food portion sizes I am receiving are small and stated, I call…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Physician Orders for Life-Sustaining Treatment (POLST-a care directive during life threatening situations) were reflected as signed and ordered by the attending physician on the resident's electronic medical record (EMR) for one of 32 sampled residents (Resident 28). This failure had the potential to cause a delay or violate resident's rights as to wishes on administering life-sustaining treatments during an emergency. Findings: During a concurrent interview and record review, on [DATE], at 10:51 a.m., with the minimum data set nurse (MDS 1) Resident 28's POLST, dated [DATE], was reviewed. Resident 28's POLST indicated .Do Not Attempt Resuscitation (DNR), provide Comfort-Focused Treatment- relieve pain and suffering with medication, use oxygen, suctioning, and manual treatment of airway obstruction, and No artificial means nutrition, including feeding tubes. Resident 28's Physician Orders (PO) in the EMR, with the run date of [DATE],…

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