Desert Springs Post Acute

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen, for 163 out of 163 sampled residents who received foods from the kitchen, when:1. A Dietary Aide did not clean dirty meal carts per facility policy and procedure;2. Calcium buildup found on hot waterspouts in the kitchen;3. Two expired sandwiches found stored inside the nourishment refrigerator;4. Dust observed on several pieces of equipment and area in the kitchen; and5. Chipped paint was observed on the water drain found under the 3-compartment sinks.These failures had the potential to result in cross contamination (bacteria are unintentionally transferred from one substance or object to another with harmful effect) and foodborne illnesses (are illnesses that result from ingesting contaminated foods). Findings: 1. On April 21, 2026, at 9:33 a.m., a concurrent observation and interview were conducted with Dietary Aide (DA) 1 in dishwashing area. DA 1 was observed using detergent to wash the dirty meal carts and then sanitized…

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 an assessment and/or an evaluation for self-administration of medication was completed, for one of 173 residents reviewed for self-administration assessment (Resident 141), when eye drop medications were found at bedside, readily available for use.This failure places Resident 141 at risk for unsafe self-administration of medications and not monitored for potential side effects and drug interactions.Findings:On April 21, 2026, at 12:04 p.m., an observation with a concurrent interview was conducted with Resident 141. Resident 141 was observed in bed, alert, and interviewable. Resident 141's bedside table was observed to have a small box of eye medication labeled as Sodium Chloride Hypertonicity Solution 5% (a sterile, over-the-counter drop used to temporarily relieve corneal edema (swelling of the eye's transparent outer layer due to fluid buildup) by drawing excess water out of the cornea) 15 ml (millimeter - unit of measurement)…

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 residents were free from unnecessary psychotropic (drug that affects brain activities associated with mental processes and behaviors) medications, for one of five resident reviewed for unnecessary medications (Resident 18), when there was no documented evidence non-pharmacological interventions (NPIs) were attempted, implemented, monitored, or documented as clinically contraindicated. These failures had the potential to place the resident at risk of unnecessary psychotropic medication use and adverse side effects, including sedation and falls.Findings:1. On April 22, 2026, a review of Resident 18's admission Record, indicated Resident 18 was admitted to the facility on [DATE], with diagnoses including unspecified psychosis (a psychotic disorder characterized by a loss of contact with reality), schizoaffective disorder (a chronic mental illness characterized by dramatic changes in thoughts, moods, and behaviors, mixed symptoms of schizophrenia…

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 necessary care and services needed to perform ADLs ( Assisted Daily Living - fundamental self-care task required for a person to live independently, such as bathing, dressing, eating, and using the toilet) for one of eight sampled residents reviewed (Resident 36), when Resident 36 was not offered supervision and/or assistance on her upper and lower body dressing.This failure resulted in Resident 36 wearing the same clothing outfit from April 20, 2026, to April 26, 2026. In addition, this failure placed Resident 36 at risk of reduced abilities in activities of daily living (ADLs) due to the lack of appropriate assistance needed to prevent such decline.Findings:The following observations and interviews, were conducted with Resident 36, who was observed to be wearing a matching blue printed flannel top and bottom from April 20, 2026 to April 22, 2026:- On April 20, 2026, at 12:14 p.m., Resident 36 was observed ambulating 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure care and treatment were provided, for two of five residents reviewed for skin management (Resident 95 and 66), when:1.For Resident 95, right anterior wrist skin redness with elevation was identified in a timely manner and was referred to the physician for treatment orders; and2.For Resident 66, the itching with redness on his neck, was identified in a timely manner and was referred to the physician for treatment orders.These failures caused discomfort for Residents 95 and 66 in the affected areas, and had the potential to increase their risk for complications due to delayed treatment. Findings: 1.On April 20, 2026, at 3:30 p.m., an observation with a concurrent interview was conducted with Resident 95. Resident 95 was observed to have a defined circular area of erythema (redness), elevated, dry with visible scaling, and mild textural changes to the top part of right wrist. In a concurrent interview, Resident 95 stated she had a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents are free from accidents, for two of three residents reviewed for accidents (Residents 177 and 140), when:1.For Resident 177, 1:1 monitoring ( staff who provides continuous, direct observation for a single patient to ensure safety) was implemented as ordered by the physician.This failure had the potential to place Resident 177 at high risk for harm and accidents; and2.For Resident 140, was not allowed to keep the cigarette and lighter by bedside according to the facility's policy and procedure.This failure had the potential to place Resident 140 at high risk of accidents.Findings:1.On April 20, 2026, at 9 a.m., an observation was conducted in Resident 177's room. Resident 177 was observed asleep in bed alone in his room. The call light was observed on top of the resident's dresser and was not within resident's reach. A call bell was observed on top of the resident's bedside table next to his bed. There was no staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure nutritional care and services were provided, for one of one sample resident reviewed for nutrition (Resident 12) when:1. The facility failed to monitor the effectiveness of nutrition interventions for Resident 12. This failure had the potential to result in delay in identifying and evaluating the necessity of an alternative nutrition approach; and2. The facility Registered Dietitians failed to follow its policy, WEIGHT CHANGE PROTOCOL to determine if meal intake of Resident 12 would be sufficient to meet Resident 12's nutritional needs. This failure had the potential to result in delay in identifying and evaluating the necessity of an alternative nutrition approach.These failures resulted in Resident 12 experiencing a 12 pound (8.5 percent) significant weight loss during a 4-months period from December 7, 2025, to April 9, 2026, and which could further impair nutrition and health status. Findings:During a review of Resident 12'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 observation, interview, and record review, the facility failed to ensure resident's nasal cannula (a medical device used to deliver supplemental oxygen) was changed on a weekly basis according to the facility's policy and procedure, for one of six residents reviewed (Resident 62).This failure had the potential to result in increased risk of infection.Findings:On April 21, 2026, at 10:45 a.m., a concurrent observation and interview was conducted with Resident 62 in his room. Resident 62 was observed receiving oxygen via nasal cannula at 2 liters per minute (L/min - unit of measurement). The nasal cannula was labeled with a date of 4/12/26 (April 12, 2026), which indicated when it was last changed. In a concurrent interview with Resident 62, he stated he used oxygen continuously. A review of Resident 62's admission Record, indicated an admission date of September 29, 2024, with diagnoses which included shortness of breath.A review of Resident 62's History and Physical, dated November 29, 2025, indicated Resident 62 had fluctuating capacity to understand and make decisions.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 interview and record review, the facility failed to ensure pain was assessed and managed, for one of three residents reviewed for pain management (Resident 20) when the licensed nurse did not assess, intervene, and obtain physician orders after the resident verbalized pain.This failure had the potential to result in unrelieved pain, discomfort, decreased quality of life, and decline in physical and psychosocial well-being.Findings:On April 21, 2026, at 8:21 a.m., during an interview with Resident 20, Resident 20 stated he requested pain medication (an acetaminophen) for arm and shoulder pain during the night shift in March 2026. Resident 20 stated the licensed nurse on the night shift informed him there was no physician order for (name of acetaminophen). Resident 20 stated he has previously been given (name of acetaminophen) without any issue.Resident 20's record was reviewed. Resident 20 was admitted to the facility on [DATE], with diagnoses which included end stage renal disease (irreversible kidney…

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 laboratory service was provided as ordered by the physician, for one of one residents reviewed (Resident 8), when the urinalysis (a small sample of your urine for signs of infection, kidney disease, or diabetes)/C&S (culture and sensitivity - a laboratory procedure that identifies infectious germs [culture] and determines the most effective antibiotic [sensitivity] to treat the infection) was not obtained as ordered by the physician.This failure had the potential for delayed care and treatment and could affect Resident 8's overall health condition.Findings:On April 21, 2026, at 11:10 a.m., Resident 8 was observed alert, resting in bed. Resident 8 was observed with a urinary/foley catheter (flexible, thin tube placed into the bladder to drain urine when you cannot pee normally). In a concurrent interview, Resident 8 stated his urinary catheter was placed due to safety reasons because he could not stand up to go to the restroom on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure dental care services and follow up treatment were provided, for one of three residents reviewed for dental (Resident 128), when there was no follow up dental consult for denture impressions after tooth extractions completed by the dentist on July 31, 2025.This failure had the potential to result in poor nutrition, and further decline in overall health. Findings:On April 21, 2026, at 11:04 a.m., Resident 128 was observed alert, resting in bed, with head of the bed elevated. Resident 128 was observed with only one tooth to the left, top front of her mouth and two teeth to the right, lower front of her mouth. Resident 128 was observed without any teeth or dentures to upper or lower posterior (back) gums. In a concurrent interview, Resident 128 stated she did not have dentures and that she wanted dentures.On April 22, 2026, Resident 128's medical record was reviewed. Resident 128 was admitted to the facility on [DATE], with diagnoses…

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 special adaptive equipment was provided to be used during meals as ordered by physician, for one of three sampled residents (Resident 62).This failure had the potential to slow down Resident 62's progress to eat independently.Findings: On April 20, 2026, at 12:18 p.m., a concurrent observation and Resident 62 meal ticket (contain Resident name, room number, physician diet order, Allergies, Adaptive Equipment, and food dislike) review were conducted with Resident 62 at Dunes dining room. Resident 62 was observed holding a spoon with right hand shaking tremendously feeding himself. Food particles were observed dropping all over on Resident 62's clothing protector and floor. Resident 62's meal ticket was concurrently reviewed and indicated, Buildup fork, Buildup knife, Buildup spoon. Resident 62 did not receive Buildup fork, Buildup knife, Buildup spoon to be used on his meal tray.On April 20, 2026, at 12:19 p.m., a concurrent interview and Resident 62 meal ticket review were conducted with Restorative…

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 safe and sanitary storage, and consumption of food items brought to the residents by family and visitors was implemented according to the facility's policy and procedure.This failure had the potential to lead to food-borne illness in medically compromised population of residents who can consume food. Findings: On April 21, 2026, at 9:22 a.m., an interview was conducted with Licensed Vocational Nurse (LVN) 8. LVN 8 stated food brought in by family and/or visitors for the residents could be stored in the nourishment refrigerator for three days. On April 21, 2026, at 10:23 a.m., an interview was conducted with Certified Nursing Assistant (CNA) 4. CNA 4 stated food brought in by family and/or visitors for the residents could be stored in the nourishment refrigerator for seven days. On April 21, 2026, at 10:25 a.m., an interview was conducted with LVN 4. LVN 4 stated food brought in by family and/or visitors for the residents could be stored in the nourishment refrigerator 24 hours to three days. During a review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident's rights to privacy was provided, for two of four residents reviewed (Residents 2 and 3), when Resident 1, who was identified with wandering behavior, entered other residents' bedrooms without permission. The failure resulted in Resident 2 and 3's right to privacy being violated and had the potential to affect psychosocial well being.Findings:On March 25, 2026, at 8:55 a.m., an unannounced visit was made to the facility to investigate resident to resident altercation.On March 25, 2026, at 9:15 a.m., Resident 1 was observed lying in bed and fidgeting around a magazine on her hand.On March 25, 2026, at 9:22 a.m., Resident 3's room was observed to be the first room off the hall from Resident 1. There were no staff observed present in the hallway to monitor the residents' whereabouts.On March 25, 2026, Resident 1's record was reviewed. Resident 1's admission Record, indicated the resident was admitted to the facility on [DATE], with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure care and treatment was provided, for two of 20 residents reviewed (Residents A and F), when:1.For Resident A, the blood sugar levels were not evaluated to address control of diabetes mellitus (abnormal blood sugar). This failure had the potential for Resident A to experience complications of uncontrolled diabetes mellitus; and2.For Resident F, episodes of diarrhea (loose, watery and possibly more-frequent passage of stool) were not addressed timely. This failure resulted in a delay in the care and treatment to address illness related to diarrhea.Findings:On February 6, 2026, at 9:45 a.m., an unannounced visit was conducted to investigate quality of care issues.1. On February 6, 2026, Resident A's record was reviewed. Resident A's admission Record, indicated the resident was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus (abnormal blood sugar).A review of Resident A's Minimum Data Set (MDS - a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure infection prevention and control measures were implemented according to the facility's policy and procedure and CDC (Centers for Disease Control and Prevention) guidelines, for five of 20 residents reviewed, when: 1.The facility staff did not wear the appropriate PPE (Personal Protective Equipment - specialized clothing or gear such as gloves, gowns, masks, respirators, and eye protection designed to protect healthcare personnel and patients from infectious materials, blood, and body fluids) when providing care to residents with C-Diff infection (Clostridioides difficile - a bacterium that causes severe, often hospital-acquired, diarrhea and colon inflammation (colitis) by producing toxins) (Resident B). In addition, the facility staff were not aware of the isolation precautions to be implemented for Resident B, and the facility staff did not wash their hands after providing care to the residents with C-Diff (Residents B and C);…

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 pharmacy consultant recommendation to check blood levels was not referred to the physician for implementation, for one of eight residents (Resident A).This failure had the potential for Resident A's overall medical condition to be affected.Findings:On February 6, 2026, at 9:45 a.m., an unannounced visit was conducted to investigate infection control issues.On February 6, 2026, Resident A's record was reviewed. Resident A's admission Record, indicated the resident was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus (abnormal blood sugar).A review of Resident A's Minimum Data Set (MDS - a resident assessment tool), dated January 17, 2026, indicated Resident A had BIMS (Brief Interview for Mental Status) score of 3 (severely cognitive impairment).A review of Resident A's Order Summary Report, included the following physician's order related to diabetes:- HgbA1C (Hemoglobin A1C - a blood test measuring average…

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 infection control precautions were implemented in accordance with the policies and procedures for two of six sampled residents (Residents 4 and 3), when: 1.Certified Nurse Assistant (CNA) 1 was observed at Resident 4's bedside wearing a face mask, and not wearing gown, gloves, and face shield. The resident requires a droplet precaution; and 2. CNA 2 was observed with Resident 3 at bedside wearing a face mask, and not wearing gown, gloves, and face shield. The resident requires a droplet precaution. These failures had the potential to increase the spread of influenza (a contagious viral infection of the respiratory tract) and cause serious illness in high-risk individuals.Findings: 1.On December 23, 2025, at 12:34 p.m., three signage and stocked PPE were observed outside Resident 4's room.A review of the three signage indicated the following: First signage, .Sequence for Putting On Personal Protective Equipment (PPE).1. Gown.2. Mask…

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 an allegation of abuse was thoroughly investigated and results of the investigation were reported to the state survey agency (CDPH - California department of Public Health) within five (5) calendar days of the incident, in accordance with the facility's policy and procedure, for two of three residents reviewed (Resident A and B).This failure had the potential for further abuse or mistreatment to other residents in the facility.Findings:On November 24, 2025, at 10:15 a.m., an unannounced visit was conducted at the facility to investigate a resident-to-resident abuse. On November 24, 2025, at 10:40 a.m., an interview was conducted with the Social Service Director (SSD). The SSD stated Residents A and B had an altercation on November 9, 2025. The SSD stated Residents A and B were married but were roomed separately. The SSD stated Residents A and B got into an argument because another resident had feelings for Resident A, and Resident B became…

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 care and treatment were provided, for one resident of six residents reviewed (Resident E), when the resident had a critical low hemoglobin (an iron containing protein in red blood cells-transports oxygen from the lungs to the body). In addition, there was no care plan developed to address Resident E's low hemoglobin levels. This failure resulted in Resident E not receiving appropriate monitoring, care and services to address critically low blood levels.Findings:On November 24, 2025, at 10:15 a.m., an unannounced visit to the facility was conducted, for an investigation of a complaint regarding quality of care. On November 24, 2025, at 2:20 p.m., an observation and attempted interview was conducted with Resident E. Resident E was in physical therapy performing upper and lower body exercises with small weights, no verbal response when spoke with resident.On November 24, 2025, a review of Resident E's medical record was conducted.…

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 an orthotic (an external brace or support used to align, support, prevent, or correct the function of the musculoskeletal system, like custom shoe inserts, ankle braces, or spinal supports, while orthotics refers to the science or practice of creating and applying these devices) consultation as recommended by the physical therapy (PT) was ordered timely, for one of five residents (Resident C).This failure had the potential to result in a delay in the rehabilitation progress of Resident C.Findings:On November 24, 2025, at 10:15 a.m., an unannounced visit to the facility was conducted to investigate a quality of care issue. On November 24, 2025, at 1:20 p.m., an interview was conducted with Resident C. Resident C stated he had been working with physical therapy and a leg brace was supposed to be ordered for him. On November 24, 2025, a review of Resident C's medical record was conducted. Resident C was admitted to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure call lights were answered as soon as possible, for one of five residents (Resident 2).This failure had the potential to cause delay of care, and to cause Resident 2's needs to not be met in a timely manner.Findings:On August 4, 2025, at 9:50 a.m., an unannounced visit was conducted at the facility for investigation of a facility reported incident involving Resident 2.A review of the facility's census indicated Resident 2 was no longer residing in the facility.A review of Resident 2's admission Record, indicated Resident 2 was admitted to the facility on [DATE], with diagnoses which included fracture of the left humerus. Resident 2 was discharged from the facility on August 2, 2025.A review of Resident 2's (Name of facility) Room History, which contained information regarding how long Resident 2's call light remained on after it was turned on, indicated Resident 2's call light was turned on on July 20, 2025, at 11:24 a.m., and remained on for 58…

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 plan of care was implemented to have another staff present while care was being provided, for one of three residents (Resident 3). This resulted in Resident 3's care plan to not be followed.Findings:On August 4, 2025, at 9:50 a.m., an unannounced visit was conducted at the facility for investigation of a facility reported incident regarding an allegation of abuse.On August 5, 2025, at 11:36 a.m., Resident 3 was observed lying on the first bed (bed A), awake and answering questions. Posted on the door of Resident 3's room was a sign indicating A Bed Cares in Pairs.Certified Nursing Assistant (CNA) 1 was observed to enter the room after putting on a disposable gown and a pair of gloves, and proceeded to change Resident 3's soiled disposable underwear, as well as clean the resident. CNA 1 stated Resident 3 was supposed to be Cares in Pairs, which meant It should be two persons all the time, but could not find anybody to assist…

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

Based on interview and record review, the facility failed to ensure an effective antibiotic surveillance program (program to help monitor the effectiveness of antibiotics, identify emerging resistance patterns, and inform strategies for infection prevention and control) was conducted, for 11 out of 12 residents (Residents 2, 8, 9, 10, 11, 12, 13, 14, 15, 16, and 17), according to the facility's policy and procedure. This failure resulted to the residents' use of antibiotic not to be evaluated for the appropriateness of its use, which could lead to development of complications related to use of the antibiotics. Findings: On May 13, 2025, at 9:35 a.m., an unannounced visit was conducted at the facility to investigate complaints on infection control. On May 13, 2025, at 3:10 p.m., during an interview with the Infection Preventionist (IP), the IP stated a list of residents on antibiotics were being printed daily and he follows up with the licensed nurses to make sure the residents are still receiving the antibiotics as ordered. The IP stated he would also check if there were any adverse…

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 TB (tuberculosis - a serious lung infection) test was completed according to the facility's policy and procedure, for two of three residents (Residents 2 and 3). This failure had the potential for TB to be undetected and could result to the transmission of the disease to the vulnerable residents. Findings: On May 13, 2025, at 9:35 a.m., an unannounced visit was conducted to investigate a complaint on infection control. On May 13, 2025, at 11:57 a.m., during an interview with Licensed Vocational Nurse (LVN) 1, LVN 1 stated a TB test was to be completed within 24 hours of admission and to be documented in the electronic Medication Administration Record (eMAR). On May 13, 2025, at 12:45 p.m., during an interview with LVN 2, LVN 2 stated a TB test was to be completed within 24 hours of admission. Resident 2's record was concurrently reviewed with LVN 2. LVN 2 stated Resident 2 was admitted to the facility on [DATE]. LVN 2 stated there was no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement the facility's policy and procedure on abuse on investigating an allegation of abuse, for one of seven residents reviewed (Resident 2) when Resident 2 reported an allegation of abuse by Physical Therapy Assistant (PTA). In addition, the facility did not suspend the PTA after Resident 2 reported an allegation of abuse. This failure had the potential to result in further abuse to Resident 2 and other vulnerable residents. Findings: On April 4, 2025, at 9:15 a.m., an unannounced visit was conducted at the facility to investigate a complaint regarding resident abuse. On April 4, 2025, at 12:45 p.m., Resident 2 was observed sitting up in bed. In a concurrent interview, Resident 2 stated the PTA was assisting her out of her bed into a wheelchair when she roughly squeezed her and caused a skin tear to her right arm last March 2025. Resident 2 further stated the Director of Rehabilitation (DOR) was aware of the allegation because…

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 report an allegation of abuse to California Department of Public Health (CDPH), immediately or within two hours after an allegation of abuse was reported, for one of seven residents (Resident 2), when Resident 2 reported an allegation of abuse by the Physical Therapy Assistant (PTA). This failure had the potential to result in delayed investigation of abuse and further exposed Resident 2 and other vulnerable residents to abuse by the PTA. Findings: On April 4, 2025, at 9:15 a.m., an unannounced visit was conducted at the facility to investigate a complaint regarding resident abuse. On April 4, 2025, at 12:45 p.m., Resident 2 was observed sitting up in bed. In a concurrent interview, Resident 2 stated the PTA was assisting her out of her bed into a wheelchair when she roughly squeezed her and caused a skin tear to her right arm last March 2025. Resident 2 further stated the Director of Rehabilitation (DOR) was aware of the allegation…

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 care and treatment was provided, for one of seven residents (Resident 2), when Resident 2 sustained a skin tear on the right wrist. This failure had the potential for a delay in the care and treatment of Resident 2 skin tear on the right wrist. Findings: On April 4, 2025, at 12:45 p.m., Resident 2 was observed to be sitting in bed with a beige wound dressing on the right wrist. In a concurrent interview with Resident 2, she stated she sustained a skin tear on the right wrist due to the blood pressure cuff being used to get her blood pressure. On April 4, 2025, Resident 2's record was reviewed. Resident 2 was admitted to the facility on [DATE], with diagnoses which included abnormalities of gait and mobility and long term use of anticoagulants (medication to prevent blood clots). A review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated March 3, 2025, indicated Resident 2 had a Brief Interview for Mental…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a sanitary environment, for one out of seven residents (Resident 7), when black mold was observed in Resident 7's shower. This failure had the potential to result in physical and psychosocial effect to Resident 7. Findings: On April 7, 2025, at 1:55 p.m., a concurrent interview and observation was conducted with Resident 7. Resident 7 stated there was a black mold in her shower. Resident 7's shower room was observed to have black grimy substance. On April 7, 2025, at 3:52 p.m., an interview and concurrent observation was conducted with the Housekeeper (HK) in Resident 7's bathroom. Black grimy substance was observed in the shower area at the corner of the bathroom. In a concurrent interview with HK, she stated the black substance looks like mold. The HK stated that it should not be there. On April 7, 2025, at 3:56 p.m., an interview and concurrent observation was conducted with the Housekeeping Supervisor (HS) in Resident 7's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the facility's policy and procedure on accounting for narcotic controlled substances was followed when: 1. The liquid Ativan (anti-anxiety medication) for one of one resident (Resident 1) was not appropriately verified against the Narcotics and Controlled Substances Count Sheet (a sheet used to monitor the administration of a medication); and 2. The off-going (end of shift) and on-coming (beginning of shift) nurses did not sign the Narcotic and Controlled Substance (Shift-to-Shift) Count Sheet, after completion of the end of shift resident narcotic medications count. These failures could have led to an inaccurate medication count, and a discrepancy in medication count records, and has the potential for drug diversion. Findings: On March 14, 2025, at 10:35 a.m., an unannounced visit was made to the facility to investigate a complaint regarding pharmacy services. 1. A review of Resident 2 ' s admission Record, indicated, Resident 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 observation, interview, and record review, the facility failed to ensure preferences were honored, for one of four residents (Resident 1), when the facility staff used bleach to clean her room despite Resident 1's request not to use bleach when disinfecting her room while she was inside the room. This failure resulted to Resident 1's preference not honored and could affect the resident's overall psychosocial well being. Findings: On March 14, 2025, at 10:40 a.m., an unannounced visit was made to the facility to investigate a complaint on physical environment. On March 14, 2025, at 12:39 p.m., during an interview conducted with Housekeeper (HK) 1, she stated she would clean the residents' rooms daily with several cleaning products, including bleach. HK 1 stated approximately 1 month prior, Resident 1 requested her not to clean her bedroom with any chemicals that smell like bleach, because the resident did not like the smell, and it made her cough. HK 1 stated she informed her supervisor of Resident 1 ' s…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the police and Adult Protective Services (APS - social services program that helps adults who are abused, neglected, or financially exploited), of an allegation of financial abuse, by an acquaintance, towards a resident, for one of three residents (Resident 1), according to the facility's policy and procedure. This failure had the potential for Resident 1 to be a victim of financial abuse without investigation from the police or APS. Findings: On February 11, 2025, at 8:20 a.m., an unannounced visit was conducted at the facility to investigate an allegation of abuse. A review of Resident 1's, admission Record, indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included encephalopathy (brain disease or damage resulting in brain function changes, including impaired memory). A review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated February 11, 2025, indicated Resident 1 had 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure human immunodeficiency virus (HIV - a virus that attacks the body's immune system) medications was administered, for one of three residents (Resident 2), according to the physician's orders. The failure had the potential to put Resident 2 at risk for an increased HIV viral load (amount of virus present in the blood), a weakened immune system & increased risk of opportunistic infections. Findings: On February 11, 2025, at 10:55 a.m., an unannounced visit was made to the facility to investigate quality of care issue. A review of Resident 2's, admission Record, indicated Resident 2 was admitted to the facility on [DATE], with diagnoses which included HIV. A review of Resident 2's, Order Summary Report, included the following physician's orders: - Dolutegravir Sodium (HIV medication), 50 MG (milligrams - a unit of measurement), one time a day, dated January 7, 2025; and - Rilpivirine Hydrochloric acid (HIV medication), 25 MG, one time a day, dated…

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 Restorative Nursing Services (RNA - services provided to help increase/and or prevent a decrease in range of motion {ROM -Full flexion and extension of a joint}), as ordered by the physician, for one of five residents (Resident 2). This failure has the potential for the resident to develop muscle contractures (permanent shortening of the muscle due to lack of use), and decreased ROM and/or mobility for Resident 2. Findings: On February 11, 2025, an unannounced visit was made to the facility to investigate a complaint on quality of care issue. On February 12, 2025, at 11:24 a.m., a concurrent record review of RNA treatments provided the week of February 2 thru 9, 2025, and interview with RNA 1 was conducted. RNA 1 stated RNA treatments were being provided to the residents to help increase their ROM and mobility. RNA 1 stated treatments were ordered by the physician and should be provided accordingly. RNA 1 stated it was important to consistently…

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 effectiveness of interventions to address multiple falls were evaluated and provide new interventions to prevent further falls, for one of three residents (Resident 1). This failure had the potential for Resident 1 to experience further falls and sustain serious injury from repeated unwitnessed falls. Findings: On January 28, 2025, at 10 a.m., an unannounced visit to the facility was made for a quality of care issue. On January 28, 2025, at 2:12 p.m., a concurrent observation and interview of Resident 1 was conducted. Resident 1 was observed resting in a low bed with blue padded mats at both sides of the bed. Bed alarm (alerts staff when resident ' s getting out of bed-{OOB}) was observed attached to the bed and a motion pad (alarms when body pressure is lifted from pad) located underneath Resident 1. Resident 1 stated she had three recent falls but could not remember the dates. Resident 1 stated she fell because, I try to do…

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 an allegation of abuse by the Restorative Nursing Assistant (RNA) towards a resident, for one of six residents (Resident 3), was reported to the California Department of Health (CDPH - State Agency) immediately or within two hours after the facility was made aware of the alleged abuse. This failure resulted in a delayed investigation by CDPH and had the potential to expose the patient to further abuse. Findings: On December 23, 2024, at 9:24 a.m., an unannounced visit was conducted at the facility to investigate facility reported incident and complaint intake. On December 23, 2024, at 1:10 p.m., Resident 3 was observed lying in bed. In a concurrent interview with Resident 3, he stated he was standing on his walker and Restorative Nursing Assistant (RNA) 1 grabbed his buttocks and squeezed it more than twice. Resident 3 stated he told his family member (FM) about the incident. On December 23, 2024, Resident 3 ' s medical record was reviewed.…

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

Based on observation, interview, and record review, the facility failed to ensure garbage bins were not overflowing and properly closed, for two of five garbage bins. In addition, trash was found on the ground beneath the dumpsters. This failure had the potential to attract pests and rodents. Findings: On January 6, 2025, at 4:50 p.m., the loading dock was observed with the Food Service Director (FSD). Two of five dumpsters were observed overflowing with boxes, the lids were not fully closed, and trash was found on the ground beneath the dumpsters. In a concurrent interview with the FSD, he stated the lids should be properly closed and trash should not be on the ground, as this could attract pests and rodents. On January 9, 2025, at 10:02 a.m., during an interview with Registered Dietitian (RD) 1, RD 1 stated the dumpster lids should be properly closed, as it attracts pests and flies, which could go the kitchen when the door is open. RD 1 further stated it would be also an infection control issue. A review of the facility's policy and procedure titled MISCELANEOUS AREAS, dated 2023,…

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 an assessment for safe self-administration of medication was conducted, for three of 165 residents (Residents 101, 265, and 19) when: 1. One opened Ventolin HFA (albuterol sulfate inhalation aerosol- medication used to prevent and treat wheezing and shortness of breath) 90 mcg (micrograms- unit of measurement) per actuation (ACT- allows the patient to operate the inhaler and directs the medicine into the patient's lungs) inhaler was found inside Resident 101's desk drawer; 2. Three opened medications were found on top of Resident 265's bedside drawer, as follows: - One Trelegy Ellipta (brand name) 30 dose inhaler (combination of fluticasone furoate, umeclidine, and vilanterol inhalation powder- medications used to treat chronic obstructive lung disease and asthma) 100 mcg/6.25mcg/25 mcg, with an expiration date of May 2026; - One Combivent Respimat (brand name for combination of ipratropium bromide and albuterol inhalation spray-…

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 call lights were answered within a reasonable time, for three of 34 residents, (Resident 95, 5, and 464). Thes failures resulted in a delay of care and had the potential for the residents' needs to not be met. (Cross Reference F725) Findings: 1. On January 6, 2025, at 3:33 p.m., an observation and concurrent interview was conducted with Resident 95 in his room. Resident 95 was observed lying in bed, alert, and agreed to the interview. Resident 95 stated he was frustrated that when he used the call light, no one would come, and if they did, they just turned the light off without addressing his needs. Resident 95 stated it would take hours before a staff would answer his call light, and this had been happening for more than two months. On January 8, 2025, Resident 95's record was reviewed. Resident 95 was admitted to the facility on [DATE], with diagnoses which included cerebral infarction (when blood flow to the brain in block), and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to uphold resident's rights when: 1. Formulation of an Advance Directive (AD - a written instruction, such as a living will, relating to the provision of treatment and services when the individual becomes unable to decide) was not offered to the resident and/or their resident representative , for seven of 13 residents reviewed for Advance Directives (Residents 514, 463, 116, 123, 263, 95, 38, and 81); and 2. Copies of the AD were not available in the medical records, for one of 13 residents reviewed for AD (Residents 13). These failures had the potential to result in the residents' wishes related to the provision of medical treatment and services, to not be followed if the residents became unable to make decisions for themselves. Findings: 1a. On January 7, 2025, Resident 514's record was reviewed. Resident 514 was admitted to the facility on [DATE], with diagnoses which included encounter for palliative care (medical approach maximizing quality of life).…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a comfortable homelike environment, for five of 165 resdients (Residents 63, 265, 28, 73, and 27), when peeled and damaged wall paper were observed inside the resident rooms 808, 212, 213, 113, and 609. These failures had the potential to affect the comfort and psychosocial well being of the residents. Findings: 1. On January 6, 2025, at 3:02 p.m., during a concurrent observation and interview with Resident 63 in room [ROOM NUMBER]. Resident 63 was observed looking at peeled and damaged wallpaper above her head board. Resident 63 stated she was not comfortable seeing the peeled wall paper. Resident 63 further stated I did not peel the wall paper. On January 7, 2024, at 3:11 p.m., during an interview with the Maintenance Supervisor (MS), the MS stated when the bed was pulled up, Resident 63's head board scraped against the wall and caused it to rip off. The MS further stated, It should have been fixed and repaired. 2. On January 7,…

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

Based on interview and record review, the facility failed to ensure the Quarterly Minimum Data Set (MDS - a resident assessment tool) assessments were submitted to the Centers for Medicare and Medicaid Services (CMS - provides health coverage) in a timely manner, for five of 10 residents reviewed fro Resident Assessment (Residents 20, 31, 33, 72, and 81),: These failures resulted in the facility being out of compliance with federal regulations. Findings: A review of the Resident Assessment Instrument Manual (RAI guidelines for resident assessment), dated October 2024, indicated, .Transmission Date No Later Than .Quarterly Assessments .MDS completion date (14 days from ARD (Assessment Reference Date - the final day of the observation period for the MDS assessment) + (plus) 14 calendar days (total of 28 days from ARD) . On January 9, 2025, the following MDS assessments were reviewed: a. Resident 20's Quarterly MDS indicated the ARD was dated November 29, 2024, and was transmitted to CMS on January 9, 2025 (41 days after ARD); b. Resident 31's Quarterly MDS indicated the ARD was dated…

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 resident's preferred activity was consistently provided, for three of three residents for activities (Resident 10, 48, and 128). This failure had the potential to result in residents to have an inactive life while in the facility. Findings: 1. On January 6, 2025, at 2:31 p.m., during concurrent observation and interview with Resident 10 in her room, Resident 10 was observed sitting at the edge of the bed and was combing her hair while watching TV. Resident 10 stated there was nothing to do but to watch TV and she would just sleep and take naps in the afternoon. Resident 10 further stated she wanted to do hair services and hair styling, I was a beautician before. A review of Resident 10's admission Record, indicated Resident 10 was admitted to the facility on [DATE], with diagnoses which included dementia (memory loss). A review of Resident 10's Minimum Data Set (MDS - a resident assessment tool), dated December 17, 2024,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure sufficient staff were provided to meet the needs of the residents, when: 1. For 15 of 165 residents (Residents 45, 101, 85, 88, 124, 91, 138, 20, 2, 139, 318, 265, 23, 104, and 123) complained of staff failing to aid with activities of daily living (ADLs- daily care activities) in a timely manner; and 2. Seven of eight confidentially interviewed residents from the Resident Council meeting complained of call lights not being answered timely, lost personal belongings, and meals not being delivered on time. These deficient practices caused feelings of frustration amoung the residents, and negatively affected the quality of care for the residents. Findings: 1a. On [DATE], at 10:39 a.m., during an interview with Resident 45, Resident 45 stated there were not enough Certified Nursing Assistants (CNA) on the night shifts and the CNAs were worked to death. Resident 45 stated the response time was very slow during the night time, with a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure provision of pharmacy services met the needs of the residents when: 1. An unopened container of Controlled II (CII, Schedule II drugs with a high potential for abuse) Emergency Kit (E-kit, a sealed container of various medications for use in emergencies) contained a small, opened E-kit medication box with no medications inside and no documentation of missing medications on the outside of the E-kit container. This failure had the potential to significantly delay treatment for pain; and 2. Three different medications lowering blood pressure were administered to Resident 103 when Systolic Blood Pressure (SBP, the top number in blood pressure reading which measures how hard the heart pumps blood into arteries) levels were below the holding parameter orders. This failure had the potential to inadequately control Resident 103's blood pressure. Findings: 1. On January 8, 2025, at 8:30 a.m., during an inspection of the CII E-kit with 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, interview and record review, the facility failed to store and label medications in accordance with the manufacturer's instructions and the facility policy and procedures when: 1. Total of three expired medications were identified in the medication refrigerator, IV/IM (intravenous/intramuscular, routes of administrations, methods of injecting medication into body) E-kit (Emergency Kit, a sealed container of various medications for use in emergencies) and the oral E-kit; 2. Total of six different medications without the open dates were stored in the medication room, the medication refrigerator, and the medication carts; 3. A discontinued order of controlled medication was stored in the medication cart; and 4. A box of ointment was stored in the treatment cart with no pharmacy-applied labels. These deficient practices had the potential for residents to receive unsafe and less potent medications, and the potential for medication errors from improperly labeled medications and the discontinued…

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 Food service staff were able to carry out the functions of food and nutrition services safely and effectively when: 1. [NAME] 1 and Food Service Director (FSD) did not follow the recipes to prepare pureed foods items (bread, chicken, and vegetable) during dinner meal on January 6, 2025; (Cross reference 803) 2. [NAME] 1 and Diet Aide 3 used water as sanitizer to clean used kitchen equipment; 3. [NAME] 1, [NAME] 2, and Diet Aide 3 did not follow manufacturer guideline instruction time length for submerging washed kitchenware in sanitizer sink; and 4. [NAME] 1, [NAME] 2, and Diet Aide 4 did not follow facility's sanitization policy and procedure to clean the used prep counter and equipment. These failures had the potential to cause foodborne illness for 161 out of 165 sampled residents who received foods from the kitchen and aspiration (accidentally inhaling food or liquid into the lungs) and providing insufficient nutrients for twelve out of twelve sample residents who had physician order for pureed…

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. Recipes were followed to prepare pureed food items (bread, chicken, and vegetables) during dinner meal on January 6, 2025. This failure had the potential for 15 out of 15 residents receiving pureed food prepared in the kitchen to not meet their nutritional needs which may lead to nutritional related health complications; and 2. Recipes for seasoning broccoli was followed during lunch meal on January 7, 2025 (Cross reference F804). This failure had the potential for 161 out of 165 residents receiving food prepared in the kitchen to not meet their nutritional needs which may lead to nutritional related health complications. Findings: 1. On January 6, 2025, at 3:25 p.m., during an observation in the kitchen, there were pureed chicken and vegetables (carrots and green beans) in separate deep pans inside the steamer. Both half of the deep pans were filled with liquid. On January 6, 2025, at 3:47 p.m., during a concurrent observation and interview with [NAME] (CK) 1, CK 1 was observed preparing pureed…

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 policy and procedure to provide appetizing and palatable (refers to the taste and/or flavor of the food) food at appropriate temperatures according to residents' preferences, for nine out of 161 sample residents, Residents 2, 3, 20, 34, 45, 87, 103, 145, and 264. This failure placed residents at potential risk to decrease nutritional intake and affect the resident's nutrition status. Findings: (Cross reference 804) On January 6, 2025, at 10:39 a.m., during an interview, Resident 45 stated the egg salad did not have any real egg cut up in it and is like baby food, the cheese enchiladas are hard and brittle. Resident 45 stated he had spoken to the manager, but nothing changed. On January 6, 2025, at 11:58 a.m., during an interview, Resident 264 stated her food was lukewarm and a little on the cold side. On January 6, 2025, at 12:05 p.m., during an interview, Resident 34 stated the food is often served cold for all meals. On January 6, 2025, at 12:10 p.m., during an interview, Resident 103 stated the…

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

Based on observation, interview, and record review, the facility failed to ensure pureed bread was prepared following the recipe, for 12 of 12 residents (Residents 18, 38, 44, 58, 96, 126, 109, 463, 513, 663, 664 and 665) who had physician prescribed order for pureed diet texture. This failure had the potential to place the residents at risk of aspiration (accidentally inhaling food or liquid into the lungs), choking and decreased meal intake. Findings: On January 6, 2025, at 3:47 p.m., during a concurrent observation and interview with [NAME] (CK) 1, CK 1 was preparing pureed bread. CK 1 stated he used a half loaf of wheat bread, 240 milliliters (a unit of measurement) of 2% milk and two tablespoons of butter to cook the bread in the steamer. CK 1 used a whisk to puree the cooked bread. The finished pureed bread appeared lumpy. CK 1 was observed not to follow any recipe when preparing pureed bread. On January 6, 2025, at 4:33 p.m., a concurrent interview and taste test (to evaluate the quality of a meal during a normal meal service and identify any areas of improvement) for pureed…

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

Based on observations, interviews, and record reviews, the facility failed to ensure evening snacks were offered to eight of nine residents (Residents 3, 124, 464, 50, 67, 76, 11, and 13). This failure had the potential to affect the nutritional and wellbeing of the residents. Findings: On January 7, 2025, at 10:30 a.m., during the resident council meeting, Residents 3, 124, and 464 stated they were not offered evening snacks. Resident 124 stated when she asked for evening snack it took a long time for nursing to get the snack for her. On January 7, 2025, at 8:03 p.m., an observation was conducted at Nurse station Dunes area. Diet Aide (DA) 1 delivered a black container consist of evening snacks to Nurse station. Each food item inside the black container was labeled with resident's name and room number, there was no extra snacks available. On January 7, 2025, at 8:09 p.m., an interview was conducted with Certified Nurse Aide (CNA) 6. CNA 6 stated he only passed evening snacks with resident's name on the food items. He never offered evening snacks for residents. CNA 6 stated if 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 observations, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when: 1. Thawed, uncooked meat (chicken and bacon) was stored in the walk-in refrigerator past their use-by dates; 2. A coffee cart was stored next to an uncovered trash bin; 3. Trash was found on the kitchen floor in multiple areas; 4. Worn-out cutting boards were still in use by dietary staff; 5. Buildup was found on different kitchen equipment; 6. Moldy, bruised, wilted, and wrinkled produce (tomatoes, cucumber, zucchini, red bell peppers and strawberries) were found in the walk-in refrigerator; 7. A rolling cart used to store soup bowls and dessert cups had chipping white coating; 8. Food residue was on the condiment tray underneath the prep area; 9. Dust accumulation in several areas of the kitchen was found; 10. An opened cheese enchilada stored in the walk-in freezer exposed to the air; and 11. An expired cranberry cocktail was stored inside the nourishment room refrigerator. These failures had the potential to cause…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a sanitary and comfortable environment, for two of seven residents reviewed for environment (Residents 22 and 63), when: 1. For Resident 22, appropriate window covering to block the light per resident's preference was not provided; and 2. For Resident 63, multiple black stained patches of bathroom floors were observed inside the resident's room. In addition, rooms [ROOM NUMBERS] were also observed to have black stained patches on the bathroom floors. These failures resulted in the resident feeling uncomfortable and disrupted the resident's daily living needs and environment. Findings: 1. On January 6, 2025, at 3:52 p.m., during a concurrent observation and interview with Resident 22 in her room, a multi-colored bath towel was observed hanging over a brown vertical window blind. Resident 22 stated she had asked the nurses to replace the window blinds with darker shades to block the light that came through the window. Resident 22…

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 treat resident with respect and dignity when the facility staff failed to cover the urinary bag, for one of four residents reviewed for dignity (Resident 516). This failure increased the potential to negatively affect Resident 516's psychosocial wellbeing. Findings: On January 6, 2025, at 10:16 a.m., Resident 516 was observed with Licensed Vocational Nurse (LVN) 1. Resident 516's urinary bag was observed attached to the resident and was filled with 110 ml (milliliter-unit of measurement) yellow liquid content. The urinary bag was observed uncovered and hanging below the level of Resident 516's bed. In a concurrent interview with LVN 1, LVN 1 stated the staff did not cover the urinary bag with a privacy bag (used to cover urine collection bag) and was exposed to everyone. LVN 1 further stated, It should have been covered, I would feel embarrassed if that bag was mine and not covered. On January 9, 2025, at 4:30 p.m., 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 observation, interview, and record review, the facility failed to ensure necessary care and services to achieve and maintain the highest practicable physical, mental, and psychosocial well-being were provided, for two of two residents reviewed (Residents 515 and 414), when: 1. For Resident 515, treatment orders were not initiated upon identification of a blister on the right heel. This failure had the potential to result in worsening of the wound, which could negatively affect the health status of Resident 515; and 2. For Resident 414, the following medications were not administered as ordered by the physician: - Eliquis (medication to reduce formation of blood clots) 5 (five) mg (milligram- a unit of measuerement); - Atorvastatin (medication used to lower cholesterol) 40 mg ; and - Gabapentin (medication to reduce nerve pain) oral solution 250mg/5ml (milliliter- a unit of measurement). This failure had the potential for Resident 414 to experience pain, discomfort and increased possibility of blood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a scheduled eye appointment was followed up, for one of one resident (Resident 50) reviewed for vision. This failure had the potential for Resident 50 to not receive the necessary treatment timely to maintain effective vision. Findings: On January 6, 2025, at 10 a.m., during a concurrent observation and interview with Resident 50 in her room, Resident 50 was observed laying on bed wearing a pair of eyeglasses with three clear adhesive tapes attached to the frame of the left lens. Resident 50 stated she needed eyeglasses to be able to read and see clearly. Resident 50 stated she requested to have an eye checkup to replace the glasses that she was using but the facility did not provide a schedule for eye appointment. Resident 50 further stated, It's a serious issue, I can't see without glasses. On January 10, 2025, Resident 50's record was reviewed. Resident 50 was readmitted to the facility on [DATE], with diagnoses which included…

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 sufficient nutrition, monitor the effectiveness of nutritional intervention, and recommend interventions to maintain an acceptable parameters of nutritional status, for one of five sampled residents (Resident 116, when: 1. Resident 116 did not receive the requested juices on his meal tray according to the diet order and resident's food preferences; 2. Resident 116 did not receive a protein substitute in the meal tray to honor the resident's preference for a vegetarian diet. In addition, the facility did not have a menu spreadsheet for a vegetarian diet; 3. There was no alternative measures implemented for resident's refusal to be weighed; 4. There was no monitoring of Resident 116's consumption of the protein shake ordered; 5. The Registered Dietitian (RD)'s recommendation to give Resident 116 protein shake supplement five times a day was not implemented or offered to the resident since July 15, 2024; and 6. There was no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interiew, and record review, the facility failed to provide pain management according to the physician's order, for one of two residents reviewed for pain (Resident 267), when the resident was not given the pain medication Norco (a narcotic pain medication) according to the physician's order. This failure resulted in Resident 267 experiencing inadequate pain relief. Findings: On January 10, 2025, at 6:30 a.m., Resident 267 was observed lying in bed, responding to name when called. In a concurrent interview, Resident 267 stated she got Norco (hydrocodone-acetaminophen- a narcotic pain medication) routinely every six (6) hours due to multiple fractures (broken bones). Resident 267 stated she had last received pain medication 14 hours ago. Resident 267 stated her pain level was 11/10 (pain scale: 1-3= mild pain, 4-7= moderate pain, 8-10= severe pain), and would not be answering any more questions until her pain was resolved. Resident 267 stated she had been asking for her pain medication since…

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 consultant pharmacist (CP)'s Medication Regimen Review (MRR) recommendation for one of five residents reviewed for unnecessary medications (Resident 50) was carried out in a timely manner. In addition, the facility's MRR policies did not include the time frames for the physician to act upon the CP's MRR recommendation. These failures resulted in inadequate monitoring and had the potential to result in ineffective medication management and to compromise the Resident 50's health. Findings: On January 9, 2025, the Resident 50's medical record was reviewed. Resident 50's admission Record, indicated was readmitted to the facility on [DATE], with the diagnoses that included hypertensive heart disease with heart failure (elevated blood pressure). A review of Resident 50's physician's order indicated furosemide (medication to reduce fluid retention and to treat high blood pressure) 20 mg (milligram - unit of measurement), 1 tablet by mouth one time…

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 antipsychotic medications (medications to treat psychotic disorders with symptoms of altered sense of reality) were ordered and used for residents with proper diagnoses and evaluations to meet residents' needs, for one of five residents reviewed for unnecessary medications (Resident 157). An antipsychotic medication for sleep received while Resident 157 was admitted in the hospital was ordered to continue with a new indication of psychosis (symptoms of psychotic disorders) without prior history of psychotic disorders and thorough psychiatric evaluation by a qualified medical professional. This failure had the potential for residents to receive an unnecessary medication with serious long term adverse effects including permanent movement disorder, seizure, and uneven heart rate. Findings: On January 8, 2025, Resident 157's medical record was reviewed. Resident 157's admission Record, indicated Resident 157 was admitted on [DATE], with diagnoses…

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 had a medication error rate of 7.14% when two medication errors occurred out of 28 opportunities during the medication administration, for two out of six residents (Resident 465 and 314). The deficient practice resulted in medications not given in accordance with the prescriber's orders and had the potential for residents not receiving the full therapeutic effects of medications with the potential for worsening of residents' medical conditions. Findings: 1. On January 7, 2025, at 9:10 a.m., during a medication administration observation with the Licensed Vocational Nurse (LVN ) 12, LVN 12 was observed preparing and administering four medications for Resident 465. One of the observed medications was Lidocaine 4% patch (topical patch medication for pain relief). A review of the Resident 465's physician's order, dated 2022, indicated, Lidoderm Patch (Lidocaine), Apply to Lt (left) shoulder/neck topically every 24 hours for neck pain and remove per schedule. The physician's order did not indicate strength of the lidocaine…

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 identify, refer, and follow up the dental needs for the resident, for one of one resident reviewed for dental (Resident 22). These failures have the potential to place the resident at high risk for complications related to dental and psychosocial needs due to the possible delay in providing dental devices. Findings: On January 6, 2025, at 3:52 p.m., during a concurrent observation and interview with Resident 22 in her room, resident was observed with missing upper and lower teeth and unable to speak words clearly. Resident 22 stated she requested the staff and social worker she wanted to see the dentist so she can have recommendation to have dentures, but she had not been seen by a dentist since admission. Resident 22 further stated, I am embarrassed to smile and it's hard to chew a food. On January 9, 2025, Resident 22's record was reviewed. Resident 22 was admitted to the facility on [DATE], with diagnoses that included depression 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 interviews and record review, the facility failed to ensure the Food Service Director (FSD - the position responsible for the day-to-day operation of the dietary department), met the educational requirements as outlined in the facility's policy, Federal Regulation, and California Health and Safety Code. Findings: According to California Code of Regulations, Title 22: Dietetic services are defined as the provision of safe, satisfying, and nutritionally adequate food for residents with appropriate staff, space, equipment, and supplies. Staffing requirements of dietetic services are such that if the position responsible for the day-to-day management of the department is not a registered dietitian there must be a full-time person who meets specific training requirements to be the dietetic services supervisor, responsible for the operation of the food service. According to the California, Health, and Safety Code - HSC § 1265.4: Qualifications of Dietary Supervisor: (b) The dietetic services supervisor shall have completed at least one of the following educational requirements:…

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 resident's beverage preference was honored on January 6, 2025 lunch and protein substitution was given on January 9, 2025 breakfast for one of one sampled resident (Resident 116). This failure resulted in Resident 116 not to receive sufficient calories and protein which could contribute to the unplanned weight loss, further compromising Resident 116's nutritional and medical status. Finding: (Cross reference 692) On January 6, 2025, at 11:37 a.m., Resident 116 was interviewed. Resident 116 stated he was a vegetarian and the vegetable that he was eating was always canned food and was not fresh. On January 6, 2025, at 12:12 p.m., a concurrent observation, interview and meal ticket review was conducted with Resident 116 at the bedside. Resident 116 was lying in bed with the noon meal tray in front of him. Resident 116's meal ticket indicated a, Regular diet, yogurt, extra Veg [vegetables], 4 fluid ounce (oz) apple juice, 4 fluid oz cranberry juice, Dislikes: Meat, Fish, eggs. Resident 116 was served…

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, facility failed to ensure infection control practices were implemented when Certified Nursing Assistants (CNA) did not wear personal protective equipment (PPE - equipment used to protect against infection or illness) when providing care to a resident with enhanced barrier precautions (EBP- infection control intervention to reduce transmission of multi-drug resistant organism [MDRO- bacteria that have become resistant to multiple antibiotics]). This failure had the potential spread infections throughout the facility, which is transferred through direct close contact of skin to skin or sharing of bedding or clothing. Findings: On January 7, 2025, at 9:37 a.m., Resident 463's door was observed to have a sign posted indicating Enhanced Barrier Precaution (EBP). Resident 463 was observed lying in bed with eyes open and the call light was on. Observed CNAs 8 and 9 to enter Resident 463's room, cleaned and changed Resident 463 without wearing a PPE. On January 7, 2025, at 9:48 a.m., during an interview with CNA 8, she stated there was no…

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

Based on observation, interview, and record review, the facility failed to ensure bed equipment in the residents' rooms were maintained in a safe operating condition, when the bed controls were observed to have damaged and exposed wirings, for two of seven residents reviewed (Residents 8 and 318). This failure to maintain a functional environment had the potential to compromise resident safety. 1. On January 6, 2025, at 9:38 a.m., a concurrent observation and interview was conducted with Resident 8 inside her room. The bed control to the left of Resident 8's bed was observed damaged, and the inner wire was exposed. Resident 8 stated she reported it a long time ago, but was never repaired. Resident 8 further stated every time she used the bed control, It makes me nervous. On January 7, 2025, at 3:08 p.m., an interview was conducted with the Maintenance Supervisor (MS). The MS stated the bed control cord was torn and the inner wires were exposed. The MS stated the bed control cord should have been fixed and replaced to prevent further damage, that led to malfunction of the device. 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, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. Certified Nursing Assistant (CNA) 1 did not use Personal Protective Equipment (PPE - equipment use to protect against infection or illness) when providing care to a resident requiring contact isolation precaution (an infection control intervention to prevent the spread of harmful germs that can be transmitted through touch); 2. Three direct care staff did not perform proper handwashing before and after proving care to a resident; and 3. The Physical Therapy Assistant (PTA - a healthcare professional who works under the supervision of a licensed physical therapist to deliver physical therapy treatments to patients) did not clean and disinfect (use of chemicals to reduce the number of bacteria or virus particles on surfaces) the gait belt (device used to aid in the safe movement of a patient) before and after resident use. These failures had the potential to increase the spread of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to transfer a resident via ambulance, on an emergent basis (unstable health condition), to the General Acute Care Hospital (GACH) for further evaluation, for one of three residents (Resident 1). This failure had the potential to delay management of symptoms of respiratory distress during transport to GACH for Resident 1. Findings: On November 14, 2024, at 8:25 a.m., an unannounced visit was made to the facility to investigate a quality of care issue. On November 14, 2024, Resident 1's record was reviewed. A review of Resident 1 ' s admission Record, indicated, resident was admitted to the facility on [DATE], with a diagnosis which included asthma (a lung disease that can make it difficult to breath). A review of Resident 1 ' s Minimum Data Set (MDS - an assessment tool), dated September 25, 2024, indicated the resident ' s Brief Interview for Mental Status (BIMS - a cognitive assessment) score of 00 (cognitively impaired). A review of Resident 1 ' s…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to reevaluate the risks and effectiveness of interventions to address incident of falls, for one of three residents reviewed (Resident 1). This failure had the potential to result in further falls and injuries. Findings: On October 17, 2024, at 8:50 a.m., an unannounced visit was conducted at the facility to investigate quality care issues. A review of Resident 1 ' s admission Record, indicated Resident 1 was initially admitted to the facility on [DATE], with diagnoses which included cerebral infarction (when blood flow to the brain is disrupted due to problems with the blood vessels that supply it), hemiplegia (paralysis on one side of the body), hemiparesis (partial weakness), chronic heart failure (heart has trouble pumping blood through the body), chronic obstructive pulmonary disease (condition that blocks air flow to the lung and makes it difficult to breathe), and cognitive communication deficit (difficulty paying attention to conversation, staying…

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 allegations of abuse involving Residents 1 and 2 to the California Department of Public Health (CDPH) within a 2-hour time frame. This failure had the potential to put residents at further risk of abuse and compromise their safety. Findings: On September 26, 2024, an unannounced visit was made to the facility for an allegation of abuse issue. A review of the abuse reporting form and Fax confirmation, dated, September 19, 2024, faxed at 10:49 a.m., indicated SSD reported, . (Resident 1) suspected abuser . (Resident 2) Victim . physical abuse . (CDPH), local police (&) State Ombudsman (advocate for residents, investigate complaints of abuse, neglect, or improper care) was notified. 1. A review of Resident 1 ' s medical records, titled, Face Sheet, indicated, resident was admitted to the facility on [DATE], with a diagnosis of congestive heart failure (Heart does not pump adequately), and unspecified psychosis (disorganized thought/behavior). 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 interview and record review, the facility failed to provide residents and/or their representatives, the right to participate in the development of an individualized plan of care (an outlined care plan, including, goals and interventions, developed in collaboration with the resident and/or their representative) for three of three sampled residents (Residents 1, 2, and 5). This failure has the potential for the resident and or resident's representative not to be aware of the care plan developed for them to obtain their health goals. Findings: On August 26, 2024, an unannounced visit was conducted at the facility to investigate a quality-of-care issue. A review of Resident 1 ' s medical records titled admission Record, indicated, the resident was admitted to the facility on [DATE], with diagnoses which included fractured (lower) spine, with routine healing. Further review of records indicated Resident 1 was self-responsible (makes his own medical decisions). A review of Resident 2 ' s admission Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide Ensure (Dietary nutritional supplement drinks) to four of four sampled residents (Residents 1, 2, 3, and 4) with their meals, in accordance with the physician order. This failure has the potential for the residents not to receive their nutritional needs. Findings: On August 27, 2024, an unannounced visit was conducted to investigate quality-of-care issue. On August 27, 2024, at 9:00 a.m., a concurrent interview with Resident 1, and observation of the resident ' s breakfast tray was conducted. Resident 1 stated, he should receive an Ensure with his meals, but he did not get one. The breakfast tray did not have an Ensure. A review of Resident 1 ' s medical records, indicated, the resident was admitted to the facility on [DATE], with diagnoses which included lower back fracture. A review of Resident 1 ' s physician orders, dated June 24, 2024, indicated, . ensure plus with meals . A review of Resident 1 ' s weights indicated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility failed to ensure the authorized resident representative was provided the opportunity to be notified of the changes in the resident's medical condition and was provided with opportunities to participate in planning the resident's care. Resident 5's representative who has the durable power of attorney (DPOA) was not listed as the resident's emergency contact. This failure has the potential for the resident's authorized representative to be unaware of the changes in the resident's condition which could result in the representative not to be able to exercise her rights to advocate for the resident. Findings: On August 26, 2024, at 8:52 a.m., during an interview, Representative 2 stated, she was appointed by Resident 5, as the resident ' s DPOA. Representative 2 stated, she called the facility (on an unspecified date) to obtain information regarding the resident ' s care, but was told that she (Representative 2) was not listed as an emergency contact for Resident 5, and there was no information which…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Physician's orders for Life Sustaining Treatment (POLST-a written medical order from a physician, nurse practitioner or physician assistant that helps give people with serious illnesses more control over their own care by specifying the types of medical treatment they want to receive during serious illness) was consistent with the Advance directive (a living will that outlines personal, medical, end of life decisions, including an assigned decision maker) for one of three sampled residents (Resident 5). This failure placed the resident at risk of not receiving the treatment or care in accordance to their choice. Findings: On [DATE], at 2:30 p.m., an unannounced visit was made to the facility to investigate a quality of care issue. A review of Resident 5 ' s admission record indicated, the resident was admitted to the facility on [DATE], with diagnoses which included End Stage Renal Disease (The final stage of kidney disease). A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the representative of missed dialysis (A medical treatment that removes waste and excess fluids from blood due to kidney failure) treatment due to hypotension (low blood pressure) for one of three sampled residents (Resident 5). This failure resulted in Resident 5 ' s Representative not to be aware of the resident ' s missed dialysis treatment, which prevented the representative to exercise rights to be involve in the care for Resident 5. Findings: On August 26, 2024, at 2:30 p.m., an unannounced visit was made to the facility to investigate a quality care issue. A review of Resident 5 ' s medical records, titled, admission Record, indicated, the resident was admitted to the facility on [DATE], with diagnoses which included end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis). A review of Resident 5 ' s Advanced Directive (a living will which appoints a medical decision…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a grievance related to a lost denture was addressed in accordance to the facility policy and procedure for one of three sampled residents (Resident 1). This failure has the potential for the resident's concerns not to be investigated and resolved. Findings: On August 26, 2024, at 8:17 a.m., an interview was conducted with Resident 1 ' s representative, who stated, she reported the resident was missing his dentures to the Social Services Director (SSD) approximately 2-3 weeks prior, and the issues has not been resolved. A review of Resident 1 ' s medical records, indicated resident was admitted to the facility on [DATE], with diagnoses which included vertebra T-11-T12 (lower back) fracture. On August 26, 2024, at 3:36 p.m., an interview was conducted with the SSD, and the SSD stated on August 15, 2024, Resident 1 ' s Representative, had reported that the resident ' s dentures were missing. The SSD stated on the same day, she followed up with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a consistent skin assessment which would include accurate measurement of wounds, were conducted on a weekly basis for three of three sampled residents (Residents 1, 2, and 3). This failure has the potential to result in the facility not to be aware of the changes in the condition of the pressure injuries subsequently delaying the provision of appropriate treatment. Findings: On June 11, 2024, at 8:11 a.m., an unannounced visit was conducted to investigate quality care issues. 1. A review of Resident 1's medical records titled, admission Record, indicated the resident was admitted to the facility on [DATE], with diagnoses which included malignant prostate cancer (spread to other parts of the body), and unspecified dementia (severe cognitive impairment). The record further indicated the resident was discharged from the facility on May 30, 2024. On June 11, 2024, at 8:40 a.m., during an interview with Treatment Nurse (Tx nurse) 1, 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 obtain treatment consent for a prescribed psychotropic medication (Seroquel- medication to treat mental or mood disorders) from the resident's responsible party prior to use, for one of three sampled residents (Resident 1). This failure has the potential for the responsible party not to be involved in the planning of care for Resident 1. Findings: On June 11, 2024, at 8:10 a.m., unannounced visit was made to the facility to investigate quality care issues. A review of Resident 1 ' s admission records, titled, admission Record, indicated the resident was admitted to the facility on [DATE], with diagnoses which included dementia (cognitive impairment). A review of Minimum Data Set (MDS- a standardized assessment tool that measures health status in nursing home residents), dated May 7, 2024, Section C: Cognitive Status indicated the resident's Brief Interview for Mental Status ({BIMS-An interview for cognitive intactness), was assessed as Severely…

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 resident's representative was informed of the changes in one of three sampled residents' (Resident 1) skin condition. This failure has the potential for the resident or the resident's representative not to be aware of the changes which could result in the representatives not to be able to exercise their rights to be involved in planning the care for Resident 1. Findings: A review of Resident 1 ' s admission records titled, admission Record, indicated, the resident was admitted to the facility on [DATE], with diagnoses which included dementia (cognitive impairment). A review of Minimum Data Set (MDS- a standardized assessment tool that measures health status in nursing home residents), dated May 7, 2024, Section C: Cognitive Status indicated the resident's Brief Interview for Mental Status ({BIMS-An interview for cognitive intactness), was assessed as Severely impaired. A review of Resident 1 ' s, History & Physical, dated, April 23, 2024, 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 interview and record review, the facility failed to notify law enforcement when reporting allegations of financial abuse involving one of three sampled residents (Resident 1). This failure had the potential for allegations of financial abuse reported by Resident 1, not to be investigated which increased the risk for further abuse on Resident 1. Findings: On May 13, 2024, at 9:00 a.m., an unannounced visit was made to the facility to investigate an allegation of financial abuse. On May 13, 2024, at 1:56 p.m., an interview was conducted with Resident 1. The resident stated he believed his family members were accessing his (Personal) bank account and stealing his funds. Resident 1 further stated, his family members canceled his debit card and were claiming it was lost or stolen. A review of Resident 1 ' s medical records titled Face Sheet, indicated the resident was admitted to the facility on [DATE], with a primary diagnosis of Encephalopathy (A group of conditions that cause brain dysfunction). A review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a dedicated 1:1 sitter (caregiver assigned to monitor one resident), was provided for two of two residents (Residents 1 and 2). In addition, the facility failed to get a physician order for a 1:1 monitoring for one of two residents (Resident 2). These failures had the potential for the two residents to be involved in another altercation which could result in serious physical injury. Findings: On May 13, 2024, at 9:00 a.m., an unannounced visit was conducted to investigate a resident-to-resident altercation incident involving Residents 1 and 2. A review of Resident 1 ' s Face Sheet, indicated the resident was admitted to the facility on [DATE], with diagnoses which included encephalopathy (A group of conditions that affect brain function). A review of Resident 1's BIMS (Brief Interview for Mental Status – mental cognition assessment tool) indicated a score of 05 (Severe cognitive impairment). A review of Resident 1 ' s physician orders dated,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an allegation of financial abuse within two hours to California Department of Public Health (CDPH) after the facility was made aware of the allegation, for one of five residents (Resident 1). This failure had the potential to result in further financial abuse for Resident 1, affecting the resident's emotional, and psychosocial well-being. Findings: On May 15, 2024, at 10:07 a.m., CDPH received a fax (facsimile - telephonic transmission of scanned-in printed material) report of a complaint involving misappropriation of property (a type of financial abuse) for Resident 1. On May 29, 2024, at 9:20 a.m., an unannounced visit to the facility was conducted to investigate a misappropriation of property issue. On May 29, 2024, at 9:40 a.m., during an interview with Resident 1, Resident 1 stated, she noticed unauthorized charges on her debit card (bank card) about the end of April 2024. Resident 1 stated she informed the Social Service Assistant (SSA). 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 interview and record review, the facility failed to ensure the resident was monitored after the resident reported an allegation of financial abuse, for one of five residents (Resident 1). This failure had the potential for the staff to be unaware of the effect on the resident's emotional and psychosocial well-being. Findings: On May 29, 2024, at 9:40 a.m., during an interview with Resident 1, Resident 1 stated, she noticed unauthorized charges on her debit card (bank card) about the end of April 2024. Resident 1 stated she informed the Social Service Assistant (SSA). A review of Resident 1's admission Record, indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses which included depression (a medical illness that negatively affects how a person feels, thinks, and handles daily activities). A review of Resident 1's Minimum data Set (an assessment tool) dated March 8, 2024, indicated a Brief Interview for Mental Status (used to identify the cognitive condition of a resident) score of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure adequate supervision was provided, for one of three residents (Resident 2) who required close monitoring and supervision, when Resident 2 was left unsupervised during care. This failure had the potential to put other residents in the facility at risk for further aggressive behaviors by Resident 2. Findings: On April 18, 2024, at 9:30 a.m., an unannounced visit was conducted at the facility to investigate an allegation of physical abuse. On April 18, 2024, at 1:17 p.m., during an observation of Resident 2's room, Resident 2 was observed to be alert, lying in bed, and watching television. No staff were observed at the bedside. On April 18, 2024, at 1:32 p.m., no staff were present in Resident 2's room, and no staff were observed entering the resident's room. Resident 2 was awake and alert in the room. On April 18, 2024, at 1:46 p.m., Resident 2 was in the room with no staff at the bedside. On April 18, 2024, at 1:50 p.m., Resident 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 report an allegation of physical abuse within 2 hours to California Department of Public Health (CDPH) after the allegation was made, for one of 3 residents (Resident 1). This failure had the potential to result in further abuse for Resident 1, affecting the resident's physical, emotional, and psychosocial well-being. Findings: On March 19, 2024, at 10:30 a.m., an unannounced visit to the facility was conducted to investigate an allegation of abuse. A review of Resident 1's record indicated, Resident 1 was admitted on [DATE], with a diagnosis which included cognitive communication deficit (difficulty with any aspect of communication that is affected by disruption of cognition), urinary tract infection (UTI – an infection of any part of the urinary system), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest.) During a review of Resident 1's Minimum data Set (MDS- an assessment tool) dated…

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 perform a background check for a direct care employee prior to employment. This failure had the potential to expose residents to abuse and exploitation. Findings: On March 5, 2024, at 4:20 p.m., during an interview with Resident 1, The resident stated about three nights ago, a Certified Nursing Assistant (CNA1) came into her room and tossed her personal items on the bed. She stated she said something to the nurse who did not really respond to her comment. She stated the following night, CNA1 and CNA2 came into her room. She stated the staff moved all her personal items, including her water and call light were moved. She stated CNA2 was mean. She stated the nurses began turning her and handling her without telling her what was going on. She stated her call light was removed and when she asked how she would get help if needed, she was instructed to yell. A review of CNA's employee records indicated the CNA's certification is current and the employee received abuse training on hire. The employee file noted to lack 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 interview and record review the facility failed to develop a care plan with interventions for one of three sampled residents (Resident 1) receiving psychotropic medications. This failure has the potential to result in Resident 1 not receiving interventions to promote the resident's optimal level of function. Findings: A review of Resident 1's admission record indicated the resident was admitted to the facility on [DATE], readmitted on [DATE]. The resident noted to have diagnoses that included TIA (Transient Ischemic Attack- interruption of blood flow to brain), anxiety disorder, hemiplegia (paralysis) affecting right dominant side, urinary tract infection, & fracture of head of left radius (left elbow). The record indicated the resident was discharged on December 2, 2023. A review of Resident 1's physician progress note dated March 10, 2023, indicated an active problem of major depressive disorder, recurrent episode. The progress note indicated the resident was alert and oriented. The progress note…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the physician or designee visited one of three sampled residents (Resident 1) every 30 days. This failure had the potential to result in Resident 1 not maintaining or achieving their highest practical level of function. Findings: A review of Resident 1's admission record indicated the resident was admitted to the facility on [DATE], readmitted on [DATE]. The resident noted to have diagnoses that included TIA (Transient Ischemic Attack- interruption of blood flow to brain), anxiety disorder, hemiplegia (paralysis) affecting right dominant side, urinary tract infection, & fracture of head of left radius (left elbow). The record indicated the resident was discharged on December 2, 2023. A review of Resident 1's records indicated the resident was seen by a physician or designate on March 10th, April 18th, May 8th & 19th, September 5th and 25th, 2023. The records did not indicate provider visits for June, July, August, nor November 2023. The resident…

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

Based on observation, interview, and record review, the facility failed to ensure for one of three sampled residents (Resident 1), the physician order to provide Resident 1 with a trapeze (a device to assist patients in transferring from one surface to another, reducing the risk of injury) was followed. This failure had the potential for the resident to have limited mobility, and being unable to transfer from one surface to another. Findings: On April 4, 2024, at 9:40 a.m., an unannounced visit was conducted at the facility to investigate a quality of care issue. On April 4, 2024, at 12:03 p.m, during a concurrent observation and interview with Resident 1 in her room, she stated, she wanted a trapeze to help her get up. Resident 1 stated, she spoke with the Social Service Director about it. There was no trapeze observed in Resident 1's room. A review of Resident 1's admission RECORD, dated April 4, 2024, indicated, Resident 1 was admitted at the facility on July 28, 2023, with diagnoses which included weakness and chronic obstructive pulmonary disease (a lung disease that block…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a copy of the written notice of transfer or discharge was provided to the long-term care Ombudsman for 30 of 50 patients, who were transferred and discharged from the facility in between [DATE], and [DATE], in accordance with the facility policy and procedure. This failure had the potential to result in the discharged residents experiencing an inappropriate transfer or discharge and to not have the opportunity to speak with the Ombudsman to advocate in protecting the resident's rights from being inappropriately transferred or discharged . Findings: On [DATE], at 11 a.m., an unannounced visit was conducted at the facility to investigate an admission and discharge issue. A review of Resident 1's admission record indicated the resident was admitted to the facility on [DATE], with diagnoses that included femur fracture (thigh bone), depression, and diabetes mellitus (inability to regulate blood sugar). A review of 1's Notice of Medicare Non-Coverage…

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 repositioning for one of three sampled residents (Resident 1) when Resident 1 was not offered repositioning. This failure had the potential to result in Resident 1 sustaining a pressure-related skin injury. Findings: A review of Resident 1's admission record indicated the resident was admitted to the facility on [DATE], with diagnoses that included diabetes mellitus, weakness, and major depressive disorder. On December 27, 2023, during an observation, at 7:13 a.m., Resident 1 noted to be sitting up in her bed with the head of bed elevated on her back. On December 27, 2023, during an observation, at 10:05 a.m., Resident 1 noted to be sitting up in her bed with the head of bed elevated on her back. On December 27, 2023, during an interview with Certified Nursing Assistant (CNA) 1, at 10:20 a.m., she stated she has worked at the facility for about 5 years. She stated residents are to be repositioned every 2 hours. She stated she has…

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 skin evaluation was conducted on admission for one of three sampled residents (Resident 1). In addition, the facility failed to ensure monitoring and treatment for non-pressure skin injuries were provided to Resident 1. These failures had the potential to result in delayed provision of care and treatment for the resident's skin condition, which placed the resident at risk for infection and complications. Findings: On November 30, 2023, at 8:40 a.m., an unannounced visit was conducted at the facility to investigate a quality-of-care issue. A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included unspecified fracture (break in continuity) of right femur (thigh bone), lack of coordination, chronic kidney disease (long standing disease of the kidneys), thrombosis (formation of blood clot within the blood vessel) of unspecified deep veins of lower extremity (both legs from…

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 nutritional assessment were completed on admission for one of three sampled residents (Resident 1). In addition, weekly weights were not completed in accordance with the policy and procedure. These failures placed Resident 1 at risk for compromised nutrition, a delay in necessary treatment and services, which has the potential to result in further decline of the resident's health status. Findings: On November 30, 2023, at 8:40 a.m., an unannounced visit was conducted at the facility to investigate a quality-of-care issue. A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included unspecified fracture (break in continuity) of right femur (thigh bone), lack of coordination, chronic kidney disease (long standing disease of the kidneys), thrombosis (formation of blood clot within the blood vessel) of unspecified deep veins of lower extremity (both legs from hip to the toes)…

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

Based on interview and record review, for one (Resident 1) of three sampled residents, the facility failed to complete the quarterly Minimum Data Set assessment (MDS - Resident Assessment and care guide tool) according to the regulation. This failure had the potential to result in the delayed assessment of residents' needs, goals of care and inability to monitor each residents' progress over time. Findings: Review of Resident 1's MDS assessment indicated section C of the last quarterly MDS assessment was completed June 9, 2023. During an interview and concurrent record review on November 7, 2023, at 3:10 p.m., the MDS Coordinator was made aware that section C of the quarterly MDS was not completed. MDS coordinator stated, there should be a BIMS [brief interview for mental status] score for September. When asked what the risk was of not completing the quarterly BIMS, MDS coordinator stated BIMS assesses for cognitive status of the patient; we would have missed the changes in his cognitive status. The most recent BIMS is in June of 2023. We had one person to handle the whole building…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an allegation of sexual abuse within two hours to the California Department of Public Health (CDPH) after the allegation was made for one of three residents (Resident A). This failure had the potential to result in further harm to Resident A ' s physical, emotional, and psychosocial (social factors and individual thoughts and behaviors) wellbeing. Findings: On June 15, 2023, at 8:03 a.m., CDPH received a report on an allegation of sexual abuse regarding Resident A and the Hospice Nurse (HN). On June 15, 2023, at 3:15 p.m., an unannounced visit to the facility was conducted to investigate an allegation of sexual abuse. A review of Resident A ' s medical record indicated Resident A was admitted to the facility on [DATE]. A review of Resident A ' s Progress Notes titled, Alert Note, dated June 14, 2023, at 6:15 p.m., indicated .patient stated she was raped, this nurse comforted and reassured patient, and let her know a report would be filed .was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure for one of three residents (Resident A), receiving hospice care (focuses on the care, comfort, and quality of life of a person with a serious illness who is approaching the end of life), was assessed on a regular basis for constipation and received medications as ordered. This failure resulted in Resident A, experiencing constipation, as well as impact her physical, mental, and psychosocial (interrelation of social factors, individual thought, and behavior) well-being. Findings: On June 15, 2023, at 3:15 p.m., an unannounced visit to the facility was conducted for a facility reported incident. On June 15, 2023, at 4:00 p.m., an interview was conducted with Resident A. Resident A stated, she remembered exactly what happened to her, the Hospice Nurse (HN) inserted something into her rectum, and it was very painful. Resident A stated, she did not feel safe, and was afraid someone else may try to put something in her rectum. A review of Resident A '…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to report an outbreak of COVID-19 (An infectious disease, which affects the respiratory system, accompanied by symptoms of fever, cough and shortness of breath, caused by the SARS-CoV-2 virus) to California Department of Public Health (CDPH). This failure resulted in CDPH to be unaware of the outbreak which caused a delay in investigation of the communicable disease outbreak. Findings: On September 26, 2023, at 10:15 a.m. an unannounced visit was made to the facility to investigate a quality care issue. Concurrently, the Administrator (Admin) reported having Covid-19 positive residents. The Administrator stated he was not sure if the COVID-19 cases had been reported by the Infection Prevention (IP) nurse to CDPH. On September 26, 2023, at 10:36 a.m. during an interview with the IP nurse, the IP nurse verified the facility currently had eight positive Covid-19 residents, and five Covid-19 positive staff members. The first Covid-19 positive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an allegation of abuse within 2 hours to California Department of Public Health (CDPH) after the allegation was made, for two of two residents (Residents 1 and 2). This failure had the potential to result in further abuse for Residents 1 and 2 affecting the residents physical, emotional, and psychosocial well-being. Findings: On September 19, 2023, at 8:50 a.m., an unannounced visit to the facility was conducted to investigate the allegations of abuse. 1. A review of Resident 1's record indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses which included intracerebral hemorrhage (brain bleed). During a review of Resident 1's Minimum Data Set (MDS - an assessment tool), dated August 17, 2023, the MDS indicated a Brief Interview for Mental Status (evaluation aimed at evaluating cognition in elderly patients) score of 0 (cognitively impaired). A review of Resident 1's General Progress Note, dated September 11, 2023 at 3:36…

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 volume of the call light was audible enough to alert staff when residents call for assistance. This failure had the potential for the staff not to be aware of the needs of residents thereby delaying provision of needed care. Findings: On July 12, 2023, an unannounced visit was made to the facility to investigate a patient's rights concern. On July 12, 2023, at 3:11 p.m., an interview was conducted with Resident 1. Resident 1 stated, It takes staff a long time to answer my (Call) light, The resident stated, Sometimes they don't even respond. A review of Resident 1's medical records, indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus (A disease where blood sugar is too high), paraplegia (paralysis of lower body), weakness, and muscle wasting. On July 12, 2023, at 11:00 a.m., an observation was made of the call light system on the Dunes Unit, at the nursing station with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure, when the alarm was triggered, the staff checked that no resident left the building. This failure had resulted to Resident A who had an exit seeking behavior (elopement risk), left the facility without the staff being aware of it, increasing the Resident A's risk for accidents. Findings: On April 14, 2023, at 2:45 p.m., an unannounced visit to the facility was conducted to investigate an accident issue. A review of Resident A's record indicated, Resident A was admitted to the facility on [DATE], with diagnoses which included dementia (memory loss). During a review of Resident A's Minimum Data Set (MDS - an assessment tool), dated October 6, 2022, the MDS indicated Resident A had a Brief Interview of Mental Status (a tool used to screen and identify the cognitive condition of residents) score of 3 (severe cognitive impairment). During a review of Resident A's Care Plan (CP), dated September 28, 2020, the CP indicated, .Exit seeking…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a copy of the Advance Directive (AD - a written statement of an individual's wishes regarding his/her medical treatment) was available in the resident's records, for three of 10 residents reviewed for AD (Residents 11, 41, and 55). This failure had the potential for Residents 11, 41, and 55's AD to not be readily available to the staff and the physician, making them unaware of, and unable to honor the resident's wishes regarding their medical treatment. Findings: 1. Resident 55's record was reviewed. Resident 55 was admitted to the facility on [DATE], with diagnoses which included cancer (disease in which some of the body's cells grow uncontrollably and spread to other parts of the body) of the neck. During a review of Resident 55's document titled Social Services Assessment and History (SSAH), dated February 25, 2022, the SSAH indicated, .Advance Care Planning .Does the patient make his/her own decisions? .No .Does the patient/patient's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the following: 1. Resident 1's splint (a rigid device to help with range of motion and to prevent or maintain range of motion) to the hand was applied daily for resident as ordered by the physician; and 2. Resident 52's skin lesion to the right forearm was assessed, monitored, and referred to the physician for further evaluation and treatment; These failures had the potential to compromise the health of Residents 1 and 52 and to lead to the development of complications in their overall health condition. Findings: On June 19, 2023, at 10:05 a.m., Resident 1 was observed in the room, sitting down in her wheelchair, awake and alert. Resident 1 was noted with left hand, fingers, and wrist hyperflexed. Resident 1 was observed without a splint or brace (device used to support or hold a body part still) on her left hand. In a concurrent interview with Resident 1, she stated she had a stroke (occurs when the blood supply to part of the…

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

Based on interview and record review, the facility failed to ensure psychotropic medications (any drug that affects brain activities associated with mental processes and behavior) were not administered without adequate monitoring for the targeted behaviors for which the medications were used for the residents. This failure had the potential to inadequately track progress toward improvement of the resident's status and for the facility to not able to measure the effectiveness of psychotropic medications. Findings: Starting on June 20, 2023, the medication records the four residents (Resident 40, 41, 42, and 46) were reviewed and the following was noted in regard to the monitoring of the targeted behavior(s) for which the psychotropic medications were prescribed for each resident: There was a physician order on December 5, 2022, for Ativan (psychotropic medication to treat symptoms of anxiety) 0.5 mg (milligram - unit of measurement) with the direction to give the resident one tablet by mouth two times day for anxiety manifested by current health concerns for Resident 40; There was a…

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

Based on interview and record review the facility failed for one of one resident reviewed for dialysis (Resident 26), to ensure Sevelamer- (phosphate binder-it binds phosphates in the stomach and prevents them from being absorbed into the body) was administered according to physician order. This failure had the potential to reult for Resident 26 to have elevated phophorus [mineral that causes body changes that pull calcium out of the bones] level. Findings: On June 19, 2023, at 3:13 p.m., during an interview with Resident 26, Resident 26 stated he was not given phosphate binder medication before meals (breakfast. lunch, and dinner). Resident 26 stated I don't get them as ordered. Resident 26 stated licensed nurses would tell him, I can not find them. Resident 2 stated he received Sevelamer twice a day instead of three times a day. During a review of Resident 26's Order Summary Report, dated February 14, 2023, indicated, .Sevelamer Carbonate Oral tablet 800 MG (milligram -unit of measurement) Give 2400 mg daily before meals for Excessive Phosphorus . During a review of Resident 26's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that the menu was followed during the tray line on June 21, 2023 when: 1. Resident 1 on regular CCHO (consistent carbohydrate) diet (a diet used in the treatment for diabetes) received a wheat roll, and a grilled cheese on white bread; 2. Resident 4 on regular CCHO diet received three (3) small plastic cups of brown sugar: and 3. Resident 214 on regular mechanical soft (easy chew) diet received fresh pineapples. These failures had a potential to result in compromising the medical and nutritional status for Residents, 1,4, and 214. Findings: On June 21, 2023, at 12:15 p.m., a review of the undated facility document titled, (name of company), Week 4, Day 25, Cycle P Lunch, was reviewed. The document indicated the following may be given: - for CCHO (Controlled carbohydrate) diet, .four (4) ounce (oz - a unit of measurement) grilled honey mustard ham steak .one half (1/2) cup whipped sweet potatoes .1/2 cup green peas .one (1)…

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

Based on observations, interview and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety when: 1. Expired foods and open foods without date were discarded and readily available for use. This failure had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food in the facility. 2. Metal sheet pans and plastic storage containers were stacked and stored wet; and 3. Dietary staff personal belongings were observed in the food preparation station. These failures had the potential to contaminate the food and cause foodborne illnesses in a medically vulnerable resident population who consumed food in the facility. Findings: 1. On June 19, 2023, at 9:53 a.m., during the initial kitchen tour with Food Safety Director (FSD), the following food items were found stored in the kitchen readily available for use: - Three (3) loaves of sliced white bread with a best if used by date of June 16, 2023; - One (1) open bag of bun (bread) with no open date; - Two (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 observation, interview, and record review, the facility failed to ensure that plan of care for repositioning was implemented for one of 18 residents reviewed (Resident 60). This failure had the potential to result in skin breakdown for Resident 60. Findings: On June 19, 2023, at 11:36 a.m., Resident 60 was observed lying on her left side, facing the window. On June 19, 2023, at 12:29 p.m., Resident 60 was observed lying on her left side, facing the window. Resident 60 stated she had been on her left side since last night. Resident 60 stated after her therapy she was placed on the same position, again and again and again. Resident 60 further stated she was only repositioned every time she had diaper change. Resident 60 was observed on supine position (lying face upward) on the following dates and time: 1. On June 20, 2023 - 9:17 a.m.; 2. On June 20, 2023 - 9: 25 a.m.; 3. On June 20, 2023 - 11:49 a.m.; and 4. On June 22, 2023 - 7: 25 a.m. A review of Resident 60's record indicated Resident 60 was admitted…

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 plan of care (POC) was reviewed and revised, for one of 18 residents reviewed (Resident 36), when Resident 36 had a decline in range of motion (ROM - the extent to which a part of the body can be moved around a joint). This failure had the potential to result in further decline of Resident 36's range of motion. Findings: On June 19, 2023, at 11:23 a.m., Resident 36 was observed lying in bed. Resident 36's left foot was extended. Resident 36 stated he did not received physical therapy for a while. A review of Resident 36's record indicated Resident 36 was admitted to the facility on [DATE], with diagnoses of left hemiparalysis (weakness on one side of the body). A review of Resident 36's Minimum Data Set (MDS - an assessment tool), dated April 10, 2023, indicated a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact). During a review of Resident 36's Care Plan (CP), dated September 7, 2021, the CP indicated,…

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

Based on observation, interview, and record review, the facility failed for one of one resident reviewed for accidents (Resident 11), to ensure: 1. An assessment was conducted and a care plan was developed for Resident 11's wandering behavior; and 2. The physician was notified for Resident 11's wandering behavior. These failures had the potential to result in injuries for Resident 11. Findings: On June 19, 2023, at 3:43 p.m., Resident 11 was observed wheeling herself in a wheelchair. In a concurrent interview with Resident 11, she stated she went to other resident's room for socialization. On June 23, 2023, at 10:55 a.m., a concurrent observation and interview was conducted with Resident 13. Resident 13 was observed in bed, awake, and verbally responsive. Resident 13 stated Resident 11, in her wheelchair, would come to his room all the time. He stated Resident 11 would eat the food and sleep in the bed of another resident (Resident 6). He stated the staff were aware of the incidents and would remove Resident 11 from his room on multiple occasions. On June 23, 2023, at 11 a.m.,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure professional standards for quality of care were followed for hemodialysis (HD- process of removing waste from the blood with the use of a machine) for one of one resident reviewed for dialysis (Resident 26), when: 1. The licensed nurse did not assess Resident 26 before and after hemodialysis on mulitple occasions. This failure increased the potential for delayed detection, reporting, and/or management of complications from the hemodialysis access sites; and 2. The licensed nurse did not communicate with the physician regarding Resident 26's missed dialysis treatment. This failure had the potential for Resident 26's physician to be unaware of the resident's medical condition after missing dialysis treatment. Findings: 1. On June 19, 2023, at 3:13 p.m., a concurrent observation and interview with Resident 26 was conducted. Resident 26's dressing on the hemodialysis access site was observed being removed by staff. The Resident 26'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 observation, interview, and record review, the facility failed to ensure provision of pharmacy met the needs of the residents when expired, discontinued, discharged resident's medications were not removed and stored in the medication storage areas along with active medications. This failure had the potential for residents to receive inaccurate, ineffective medications. Findings: On June 20, 2023, at 1:45 p.m., during the medication room inspection in Oasis Nursing Station with LVN 2, it was noted there were following expired medications in the medication refrigerator: Eleven boxes of containing ten 0.5-ml (milliliter - unit of measurement) prefilled FLUAD (flu vaccine) syringes; and Three bags of vancomycin (injectable antibiotic for infection) 500 mg (milligram - unit of measurement) in 100 ml of fluid with the expiration date of May 29, 2023. Also, there were following medications for a discharged resident on the cabinet shelf along with other active medications: One 30-gram Nystatin cream (antifungal cream); One 22-gram mupirocin (antifungal ointment) ointment 2%; One…

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 document and record review, the facility failed to ensure medication irregularities were identified during monthly medication regimen review (MRR) by the Consultant Pharmacist (CP) and recommendations were made to ensure appropriate use of medications for one of five residents reviewed. Resident 40 received a medication not recommended for use in the adults 65 years or older by the American Geriatric Society's Beers Criteria. This failure had the potential to expose the resident to adverse effects such as increased risk of falls, delirium, and dementia. Findings: On June 20, 2023, Resident 40's medical record was reviewed, and the following was noted: The resident was a [AGE] year-old male who was admitted to the facility on [DATE], with diagnoses that included hypotension (low blood pressure), major depressive disorder and unspecified psychosis; There was a physician order on June 17, 2023, for hydroxyzine (medication for anxiety or allergic symptoms) 50 mg (milligram - unit of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were free from unnecessary medications when one of five residents reviewed (Resident 49) was receiving four different pain medications as needed without specific parameters indicating which pain medication to be given ahead of others based on the level of pain perceived by the resident. This failure had the potential for the resident to unnecessarily receive stronger narcotic pain medication for minimal pain. Findings: On June 20, 2023, Resident 49's medical record was reviewed, and the following was noted: The resident was a [AGE] year-old female who was admitted to the facility on [DATE], with diagnoses that included primary osteoarthritis (joint pain), hereditary and idiopathic neuropathy (inherited and unknown nerve pain); There was a physician order on June 20, 2023, for naproxen (pain medication) 500 mg (milligram - unit of measurement) with the direction to give the resident one tablet by mouth two times a day for pain; There…

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 for one of three residents reviewed for choices (Resident 8), resident's food preference was honored. This failure had the potential for Resident 8 not being able to enjoy her preferred food, resulting in decrease oral intake. Findings: On June 19, 2023, at 2:35 p.m., Resident 8 was interviewed. Resident 8 stated two or three days ago she requested for beef soup. She further stated she was not served the beef soup and was given a corn chowder instead. A review of Resident 8's record indicated, Resident 8 was admitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease (a breathing related problem). During a review of Resident 8's Minimum Data Set (MDS - an assessment tool), dated April 26, 2023, the MDS indicated, .Brief Interview of Mental Status .Score of 15 (cognitively intact) . During a review of Resident 8's Care Plan (CP), dated April 25, 2023, the CP indicated, .Nutritional Status .Goal .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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure standard infection control practices were implemented when: 1. A staff member (CNA - Certified Nursing Assistant) did not perform hand hygiene after picking up a finished meal tray from the resident's room; and 2. An uncovered urinal (receptacle used for urinating) with half-filled urine in the resident's room was hanging on the side of the trash can next to the resident's bed. These failures had the potential to spread infection and comprise the overall health status of the residents residing in the facility. Findings: 1. On June 19, 2023, at 12:20 p.m., during lunch meal observation, a staff member was seen leaving Resident 50's room and carrying a meal tray for a resident. The staff member was observed to place the meal tray on the meal cart in the hallway before returning to Resident 50's room. The staff member proceeded to care for a resident in room [ROOM NUMBER] C bed without performing hand hygiene. On June 19, 2023, 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.

Based on interview and record review, the facility failed to ensure in-services provided was sufficient when one certified nursing assistant (CNA) did not complete twelve hours of in-service trainings for the year 2022. This failure had the potential to affect the quality of care and services provided to the residents. Findings: A review of the facility's In-Service log for the year 2022, indicated, CNA 1 had completed three hours of the 12 hour-mandatory in-service for the CNAs. On June 23, 2023, at 11:30 a.m., during a concurrent interview and record review with the Director of Staff Development (DSD), she stated she provided education to the staff. The DSD stated, CNAs should be receiving 24 hours of in-services per year. She stated CNA 1, should have been provided 24 hours of in-service per year instead of three hours. The DSD stated the facility did not have a policy and procedure regarding in-service trainings for CNAs.