California Nursing & Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure needed treatment and services were provided to maintain range of motion (ROM- full movement potential of a joint) for one of three sampled residents (Resident 4) when Resident 4's Restorative Nursing Program (a nursing-driven service in long-term care settings that helps residents maintain or improve their functional abilities to their highest possible level) orders were not followed and in accordance with Resident 4's plan of care.These failures had the potential to cause further decline in functional mobility, ROM, and quality of life for Resident 4.Findings:During an initial tour observation on 5/4/26 at 3:47 PM, inside Resident 4's room, Resident 4 was awake, verbally responsive, and lying in bed. Resident 4 had a left arm sling and was observed with limited movement in the arms and legs.A review of Resident 4's Face Sheet (front page of the chart that contains a summary of basic information about the resident) dated 5/7/26,…

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

Based on interview and record review, the facility failed to ensure accurate accountability of controlled substances (CS - medications with high potential for abuse and addiction) for two of six randomly selected residents (Residents 45 and 51) who were reviewed for controlled substance accountability when:Resident 45's Tramadol (an opioid medication used to treat moderate to moderately severe pain) Individual Narcotic Record (inventory records used to document receipt, use, and count of controlled substances [medications with potential for abuse and dependence]) did not match the Medication Administration Record ([MAR] a daily documentation record used by a licensed nurse to document medications and treatments given to a resident).Resident 51's Percocet (an opioid medication used to treat severe pain) Individual Narcotic Record did not match the MAR.These failures resulted in an inaccurate accountability of controlled substances and had the potential for diversion (controlled substances used by someone other than the resident for whom the medication was prescribed), or misuse 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 adequately monitor one of 17 sampled residents (Resident 34) for side effects (secondary, often predictable, unintended effects of a medication that can be beneficial, neutral, or harmful) and adverse drug reactions (strictly unintended, harmful, and unexpected reaction of a medication, usually requiring intervention) for the use an anticoagulant (medication that thins the blood to prevent blood clots) medication per facility's policy.This failure had the potential to result in adverse outcomes, including bleeding complications, bruising, hemorrhage, hospitalization, or other medication related complications associated with anticoagulant use.Findings:During an initial tour observation on 5/4/26, at 3:45 PM, inside resident's room, Resident 34 was lying in bed, awake, and watching TV.A review of Resident 34's Face Sheet (front page of the chart that contains a summary of basic information about the resident) dated 5/7/26, indicated…

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

Based on observation, interview, and record review, the facility failed to ensure medications were administered in accordance with physician orders when a medication error rate of 8% was identified, with two medication errors out of 25 medication administration opportunities, during medication administration observations for one of four residents observed (Resident 39).These failures included the administration of an incorrect dose and an incorrect dosage form of medications, which had the potential to compromise the resident's medication therapy and safety.Findings:During a medication administration observation for Resident 39 on 5/4/26 at 8:58 AM, Licensed Vocational Nurse (LVN) 4 prepared and administered 17 medications, including two tablets of Senna (medication used to treat constipation) 8.6 mg (milligram - unit of measurement) and one tablet of OxyContin CR (controlled-release narcotic pain medication designed to release slowly over time) 10 mg.A review of Resident 39's Physician's Orders indicated the following physician's orders dated: 4/6/26, Senna Oral Tablet (Sennosides…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 81) reviewed for unnecessary medications was free from a significant medication error when, Resident 81 did not receive phenobarbital (a controlled substance used to control seizures [a sudden, uncontrolled electrical disturbance in the brain that may cause involuntary jerking movements, staring spells, and/or loss of consciousness] by stabilizing electrical activity in the brain) as ordered by the physician for five consecutive days. The facility failed to ensure the physician was notified of the missed doses and failed to follow-up on the status of the medication with the facility's contracted pharmacy.This failure resulted in missed doses of anticonvulsant (seizure-control) medication and had the potential for decreased medication levels in the body and increased risk for seizure activity.Findings:A review of Resident 81's Face Sheet, (front page of the chart that contains a summary of basic information…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement infection control and prevention measures when:1. The sharps container (a puncture-resistant, leak-proof receptacle designed for the safe disposal of medical sharps to prevent injury and infection) on one of three medication carts (Medication Cart 2) was filled beyond the fill line indicator.2. The Certified Nurse Assistant (CNA) 1 failed to follow the facility's policy for Enhanced Barrier Precautions ([EBP] - an infection control prevention designed to reduce the transmission of multi-drug-resistant organisms (MDROs) in healthcare settings, particularly nursing homes) when CNA 1 did not wear a gown while providing incontinent care to Resident 60.These failures had the potential for increased risk of infection which can compromise the health and wellbeing of residents, staff, and visitors.Findings:1. During a concurrent observation and interview on 5/4/26 at 11:16 AM, with License Vocational Nurse (LVN) 1, LVN 1 was observed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two of five sampled residents (Residents 17 and 52) reviewed for immunizations, were offered the COVID-19 (contagious respiratory illness caused by the SARS-CoV-2 virus) vaccine and failed to maintain documentation of vaccine education, refusals, or acceptance.These failures had the potential for Residents 17 and 52 to be unprotected against COVID-19, increased the risk of serious illness, delayed identification of vaccine status, and missed opportunities to prevent the spread of infection within the facility.Findings:A review of Resident 17's admission Record, (a document showing a summary of the resident's information) dated 5/24/23, indicated Resident 17 was readmitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary ([COPD] - a progressive lung disease which blocks air flow making breathing difficult), shortness of breath, and muscle weakness.A review of Resident 52's Face Sheet, (front page of the chart…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 administer the resident's morning medications and notify the doctor (Dr) on February 20, 2026, for one of three residents reviewed (Resident 1).This failure had the potential for Resident 1 to experience adverse effects from not receiving their morning medications as ordered.Findings:On March 9, 2026, an unannounced visit was made to the facility for a Quality-of-Care issue.A review of Resident 1's, Resident Information, indicated, the resident was admitted to the facility on [DATE], with a diagnosis of Pulmonary Embolism (A blood clot in the lungs).Further record review indicated Resident 1 had a Brief Interview of Mental Status (BIMS-a cognitive assessment) score of 15, no cognitive impairment.On March 9, 2026, at 11:15 a.m., an interview was conducted with Resident 1 who stated she did not receive her morning (9:00 a.m.) medications on February 20, 2026. Resident 1 stated she did not experience any adverse side effects from missing her morning…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure proper infection control precautions were implemented for one of two residents (Resident 1), when a staff member was observed returning an unused dinner tray from a COVID (Corona virus - a contagious respiratory disease) positive residents isolation room (A room that separates residents from others, while receiving specialized medical treatment) to the meal cart which stored trays that were being served to other residents.This failure had the potential to cross contaminate clean resident dinner trays and spread COVID infection to uninfected residents. Findings:On August 26 and 27, 2025, unannounced visits were made to the facility to investigate infection control, safety, and quality of care issues.On August 26, 2025, at 2:10 p.m., an interview was conducted with the Infection Prevention (IP) Nurse, who stated the facility had two COVID positive residents sharing an isolation room. The IP stated an in-service was recently provided…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 gastrostomy tube (g-tube, a tube inserted through the abdomen into the stomach, to deliver fluids and nutrition) stoma (opening) dressing change daily, for one of three residents reviewed (Resident 2).This failure had the potential to lead to skin breakdown or infection at/or around the stoma site.Findings:On July 28, 2025, at 1:10 p.m., an unannounced visit was made to the facility to investigate complaints related to quality of care. On July 29, 2025, at 8:44 a.m., an interview with the Treatment (Tx) Nurse was conducted. The Tx Nurse stated she was going to perform the dressing change on Resident 2's g-tube stoma site and that the dressing change is to be provided daily. A review of Resident 2's Resident Information, indicated resident was admitted to the facility on [DATE], with a diagnosis of stroke and dysphagia (difficulty swallowing). Resident 2 had a Brief Interview of Mental Status (BIMS-a cognitive assessment) score…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately monitor and document total fluid intake via gastrostomy tube (g-tube, tube inserted through the abdomen, into the stomach to administer medications, nutrition and hydration) and the output (I &O) per physician orders, for two out of three residents (Residents 1 and 2). This failure had the potential to result in resident dehydration leading to other health complications such as decreased urine output, dizziness, rapid heart rate, and altered mental status.Findings: On July 28, 2025, at 1:10 p.m., an unannounced visit to the facility was made for a quality-of-care issue.1. A review of Resident 1's Resident Information, indicated, resident was admitted to the facility on [DATE], with a diagnosis of dysphagia (difficulty swallowing), and g-tube. Resident 1 had a Brief Interview for Mental Status (BIMS-a cognitive assessment) score of 6 (severe cognitive impairment). A review of Resident 1's, Care Plan dated April 5, 2022, titled, (Resident 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide wound treatment in accordance with the physician order for one of three sampled residents (Resident 1). This failure had the potential to delay wound healing for Resident 1. Findings: On June 6, 2025, at 8:05 a.m., an unannounced visit was made to the facility to investigate quality-of-care issues. A review of Resident 1 ' s admission record indicated that the resident was admitted to the facility on [DATE], with diagnoses which included peripheral vascular disease (narrowed blood vessels reduce blood flow to affected limbs). A review of Resident 1 ' s Minimum Data Set (MDS- an assessment tool) dated March 26, 2025, indicated the resident ' s Brief Interview for Mental Status (BIMS- a cognitive assessment) had a score of 15 (cognitively intact). A review of Resident 1 ' s Skin Issues, dated June 2, 2025, indicated resident had a front left (outer) chronic leg wound, measuring 8 centimeters ({cm} – a unit of measure) in length X…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 smoking precaution, by not providing a smoking apron (worn while smoking to help decrease incidents of burning self), to one of four residents (Resident 1) while smoking cigarette at the facility patio. This failure had the potential for Resident 1 to sustain burn injuries while smoking a cigarette. Findings: On May 9, 2025, at 10:30 a.m., an unannounced visit was made to the facility to investigate a quality-of-care issue. On May 9, 2025, at 10:50 a.m., during an observation of residents smoking on the patio, the Activity Assistant (AA) was observed taking the smoking apron and placing the apron to Resident 1 who was almost done smoking his cigarette. The AA stated she forgot to put the smoking apron to the resident (Resident 1). On May 9, 2025, at 10:53 a.m., during an interview, the AA stated she was on the patio to supervise the residents smoking. The AA stated, when residents smoke, she would hand out the cigarettes and an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure a Registered Dietitian (RD) carried out the functions of the registered dietitian when: 1. Timely monitoring of nutrition interventions was not conducted to meet the needs of 5 sampled residents, (23, 43, 51, 58 and 673) who experienced severe unintentional weight losses greater than 7.5% in three months; 2. The Diet manual was not updated, and facility menus were not followed; and 3. Unsanitary and unsafe food practices were conducted in the kitchen. These failures placed vulnerable residents at risk to poor improper practices that had the potential to further weaken and compromise their nutrition and health status based on their medical diagnoses. The facility census was 72. Cross reference F692, F803, F804, F812 Findings: 1. During a review of The Academy of Nutrition and Dietetics Evidence Analysis Library regarding Unintended Weight Loss for Older Adults Evidence-Based Nutrition Practice Guidelines, dated 2007-2009, .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 food safety and sanitation practices were maintained in the kitchen according to standards of practice and facility policy when: 1. The ice machine was not properly maintained and cleaned per manufacturer guidelines; 2. The dish machine sanitizer solution was outside of the correct chemical range and tested 300- 400 ppm (parts per million- a unit of measurement); 3. Kitchen staff did not wear beard nets while working in the kitchen; 4. Dishes and three (3) large metal pans with food debris and dripping water on them were stacked on top of each other in a drawer; and 5. Kitchen staff were using cloth oven mitts that were wet, soiled, and had food build-up/residue on them. These failures exposed resident's to contaminated food and unsanitary practices, which placed residents at risk of developing foodborne illness and compromise their health. The facility census was 72. Cross reference F802 and F908 Findings: 1. On February 24, 2025, at 10:38 a.m., a joint observation and interview was conducted at 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 have a written Quality Assurance Performance Improvement (QAPI - a systematic, interdisciplinary, comprehensive, and data-driven approach to maintain and improve safety, quality of care, and quality of life of the residents) plan in place to address the facility's systemic process issues related to weight loss, kitchen and nutrition services, and broken call light systems. These failures resulted in multiple residents to not receive appropriate care and treatment for weight loss and delayed response to residents' call lights. In addition, these failures had the potential for other residents at risk to not achieve their highest physical, mental, psychosocial well-being. Findings: During the survey, systemic issues were identified with weight loss (see findings under F692), kitchen and nutrition services (see findings under F800, F801, F802, F803, F804, F812, F813, F908), and timely identification and repair of broken call light bell system (see findings under F919). On March 3, 2025, at 2:40 p.m., an interview and a…

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

Based on observation, interview, and record review, the facility failed to ensure essential food and nutrition services equipment, such as the reach in freezer, and ice machine were maintained in safe operating condition. These failures had the potential to impact the ability of dietary staff to prepare, store, and serve food in a safe and sanitary manner. Resident census was 72 at time of survey. Findings: 1. During the initial kitchen tour on February 24, 2025, at 9:15 a.m., a concurrent observation and interview with [NAME] (CK) 1 was conducted at the reach in freezer. The freezer was full of bags of mixed vegetables on the middle shelf, cases of chicken and beef at the bottom shelf and large tubs of ice cream along with pre-cooked bread rolls. The ice cream was very soft, and tub was bendable. The temperature internal temperature of the freezer was 54 degrees Fahrenheit (F). A surveyor placed their digital thermometer inside the reach in freezer and the temperature was 49.8 degrees F. CK 1 acknowledged the refrigerator's internal temperature and stated, it should be 32 degrees.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 call light system (a communication system that allow the residents to call for staff assistance) was fully functional when: 1. The call light system panel did not have an audible sound; and 2. Resident 23 did not have a call light button installed, available, and within reach. These failures had the potential for Resident 23 and the residents in the facility not to receive assistance from the staff in a timely manner. Findings: 1. On February 26, 2025, at 9:45 a.m., the call light panel located on the wall of the nurse's station was observed with the light on for room [ROOM NUMBER]. The call light panel did not have an audible sound while the light was on in room [ROOM NUMBER]. On February 26, 2025, at 9:51 a.m., during a concurrent interview and record review with the Registered Nurse Supervisor (RNS), the RNS stated there should be an audible sound heard from the call light panel when a light is on. The RNS 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 provision of pharmacy services met the needs of the residents when: 1. An emergency supply kit (E-kit, a sealed container with various medications for use in emergencies) containing controlled substance (CS, those with high potential for abuse and addiction) medications was stored opened and unsealed; 2. Residents 17 and 50 were missing documentation for the administration of CS medications. The CS medications were signed out of the Individual Narcotic Record (count sheet, an inventory sheet that keeps record of the usage of CS medications) but not documented on the Medication Administration Records (MAR) to indicate they were administered to the residents; Additionally for Resident 17 the CS medications were documented on the MAR but not signed out of the count sheet; and 3. For Resident 50, nursing staff did not ensure the CS medication received from the pharmacy matched the current physician's order according to the facility's policy and procedures. These failures had the potential for CS medication…

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

Based on observation, interview, and record review, the facility did not ensure the kitchen staff in the food and nutrition services department were trained according to standards of practice for food safety, sanitation, and facility policy when: 1. A [NAME] did not know how to use the chlorine test strips to test the sanitizer in the dish machine. 2. A Dietary Aide did not know how to calibrate a food thermometer. These failures in staff competency resulted in exposing 72 residents who consume food from the kitchen to practices associated with food borne illness as well as bacterial and chemical cross contamination and had the potential to cause illness. Findings: 1. On February 24, 2025, at 10:32 a.m., [NAME] (CK) 2 demonstrated how to test the sanitizer in the dish machine and described how it operated. CK 2 dipped a test strip from the container and compared the color shades of lavender to purple. CK 2 stated it was dark purple which was 300 ppm to 400 ppm (parts per million, a measure of units), and it should be 100 ppm to 200 ppm, according to the test strip container. On…

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

Based on observation, interview, and record review, the facility failed to ensure the food was served at an acceptable temperature and palatability taste to the residents, according to the facility policy. This failure had the potential to affect meal and food intake which could impair the nutrition status of the 74 residents who consumed food from the kitchen. Cross Reference F800, F801, F803 During a review of the facility's Winter Menu, Week 4, the Tuesday 2/25/25 lunch meal for the Regular diet included 3oz (ounces) of herb crusted beef roast, 1/2 oz brown gravy, ½ cup mashed potatoes, ½ cup zesty spinach, parsley sprig garnish, 1 slice of garlic bread, and 1 Sq. (square) triple fruit crisp. The pureed (food made into a creamy substance) meal included ½ cup pureed herb crusted beef roast, 1/3 cup mashed potatoes, 1/3 cup zesty spinach, ¼ cup garlic bread, and 1/3 cup triple fruit crisp. On February 24, 2025, at 9:32 a.m., a Resident Council meeting was conducted. During the meeting, multiple residents anonymously stated the food is served cold. On February 24, 2025, at 11:06…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 infection control practices were implemented when: 1. The laundry room door was closed and staff were observed passing through the clean area of the laundry from the hallway; 2. Nursing staff failed to properly clean and disinfect shared blood pressure (BP-pressure of blood in blood vessels) cuffs and stethoscopes for Residents 475 and 58, according to the disposable Sani-Cloth disposable wipe manufacturer's specified contact time (the time the resident equipment was to be in contact with the disposable wipes to kill micro-organisms). In addition, the facility failed to properly clean and disinfect the shared stethoscope after use according to facility's policy; and 3. The lunch meal trays for Residents 17 and 23 were placed in the residents' room next to unsanitary bodily equipment. These failures had exposed vulnerable residents to potentially hazardous substances due to cross-contamination, which could increase development of infections. Findings: 1. On February 27, 2025, at 8:53 a.m., a concurrent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, for one of one resident reviewed (Resident 23), to ensure Resident 23 was appointed a resident representative (RR- someone who can act on behalf of a resident, typically a family member, guardian, or someone with legal authority, to make decisions regarding the resident's care and rights). This failure had resulted in Resident 23 not having a resident representative to exercise their rights or delegate Resident 23's medical decisions. Findings: On February 25, 2025, at 10:57 a.m., Resident 23's record was reviewed. Resident 23 was admitted to the facility on [DATE], with diagnoses that included altered mental status (change in a person's level of consciousness, awareness, and cognitive functions), disorder of the brain (conditions that impact the brain's normal functioning), psychosis (a mental health condition characterized by a loss of contact with reality). The document titled, History and Physical (H&P) dated July 2, 2020, indicated, .can make needs…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 exercise reasonable care for the protection of resident's property from theft and loss for one of two residents reviewed for personal property (Resident 21). This failure resulted in Resident 21's violation of resident's rights of having a safe environment. Findings: On February 24, 2025, Resident 21 was observed lying in bed, awake and alert. She stated she was missing some personal belongings since she was transferred from another room two weeks ago. Resident 21 stated she was missing a hairbrush, expensive make-up, house slippers and pajamas. She stated she told a staff the day she noticed some of her personal belongings were missing. Resident 21 stated she could not remember the exact date she talked to a staff about her missing personal belongings and who she talked to. She stated she talked to another staff this morning, but she could not recall the staff's name. On February 25, 2025, at 9:13 a.m., Resident 21 was observed lying in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed, for one of one resident reviewed (Resident 23), to ensure a follow-up with the local authority for the completion of a Level II Preadmission Screening and Resident Review (PASARR- a federally mandated process ensuring individuals with mental illness, intellectual/developmental disabilities, or related conditions receive appropriate placement and services in Medicaid-certified nursing facilities) was performed. This failure had the potential for Resident 23 to not receive the appropriate care according to his mental and behavioral needs. Findings: On February 24, 2025, at 10:48 a.m., Resident 23 was observed in bed, alert, confused, and yelling. On February 25, 2025, at 10:57 a.m., Resident 23's record was reviewed. Resident 23 was admitted to the facility on [DATE], with diagnosis that included altered mental status (change in a person's level of consciousness, awareness, and cognitive functions), disorder of the brain (conditions that impact the brain'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 for one of two residents reviewed for care planning a care plan was initiated for toe nail fungus (Resident 43). This failure had the potential to result in ineffective treatment of foot care and cause pain or discomfort to resident 43. Findings: On February 28th, 2025, at 10:47 a.m. an observation was conducted of Resident 43's feet. Resident 43's was laying in bed, both feet had dry flaking skin and hypertrophic nails. (thickened from toenail fungus). A review of Resident 43's record indicated Resident 43 was admitted to the facility on [DATE], with diagnoses which included Peripheral Vascular Disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs). Resident 43's podiatry (medical doctor who specializes in feet and toe nails) note dated February 19, 2025, indicated, .Dermatologic Evaluation: Onychomycosis (type of toe nail fungus) . Right and left toenails 1-5, .Onychohypertrophy (thickened toenails…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 services provided met professional standards of practice for two of 72 residents (Residents 57 and 58) reviewed when: 1. For Resident 57, one Albuterol Sulfate inhaler (medication used to treat breathing problems caused by lung disease) was observed on top of the resident's nightstand: and 2. For Resident 58, the facility did not clarify a physician's order for Vitamin D3 (a type of Vitamin supplement). These failures had the potential for Resident 57 to receive the Albuterol Sulfate inhaler without a physician's order, and for Resident 58 to receive a wrong dose for the Vitamin D3. Findings: 1. On February 24, 2025, at 9:58 a.m., Resident 57 was observed sitting in bed, leaning on the bedside table while reading a paper. Resident 57 was using oxygen at 4 liters (unit of measurement) per minute via a nasal canula (a device that delivers oxygen through a tube and into the nose). A bottle of Albuterol Sulfate inhaler was observed 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 for one of 18 residents reviewed (Resident 224), multiple dry scabs located on bilateral (both) forearms was referred to the physician for treatment orders. This failure had the potential to result in Resident 224's skin condition to persist without prompt intervention thereby causing a possible further decline in health condition. Findings: On February 25, 2025, at 8:47 a.m., an observation with a concurrent interview was conducted with Resident 224. Resident 224 was observed to have multiple dry scabs, brownish black in color, and variable in size, on both upper extremities (arms). Resident 224 stated he had the scabs prior to his admission to the facility. On February 25, 2025, at 11:54 a.m., an interview was conducted with Resident 224's family member. The family member stated Resident 224 was admitted to the facility with the multiple scabs to his bilateral forearms and he was treating the scabs with his own Neosporin (type of…

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

Based on observation, interview, and record review, the facility failed to ensure safe smoking practices were observed and implemented for one of eight residents reviewed for smoking (Resident 12), when Resident 12 had cigarettes and lighter in his possession. This failure had the potential to result in accidents or injuries to the facility residents. Findings: On February 24, 2025, at 12:33 p.m., a concurrent observation and interview was conducted with Resident 12. Resident 12 was observed in his room, sitting on his bed, with oxygen on via nasal cannula (NC - a tube that delivers oxygen to the nose). A pack of cigarettes was observed in Resident 12's nightstand drawer. Resident 12 stated the pack of cigarettes was his and he went out to smoke on the smoking patio every day. Resident 12's roommate was also observed in his bed, with oxygen on via NC. On February 25, 2025, at 8:30 a.m., an observation was conducted on the smoking patio. Resident 12 was observed taking a cigarette lighter out of his pocket, handing it to another resident who lit up a cigarette, and who returned it to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed, for one of one resident reviewed (Resident 23), to ensure bowel and bladder assessment and evaluation was performed for ascheduled toileting program. This failure resulted in no bladder training program for Resident 23 which had the potential to lead to further decline of bladder function. Findings: On February 24, 2025, at 10:48 a.m., an observation with a concurrent interview was conducted with Resident 23. Resident 23 was in bed, alert, and interviewable. Resident 23 stated he used incontinence pads and needed a nurse to help him change. On February 24, 2025, at 9:47 a.m., Resident 23's record was reviewed. Resident 23 was admitted to the facility on [DATE], with diagnoses that included altered mental status (change in a person's level of consciousness, awareness, and cognitive functions), diabetes mellitus (chronic condition characterized by high blood sugar). The document titled, Care Plan, dated January 19, 2022, indicated, .Focus…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 respiratory care and treatment for one resident reviewed for oxygen administration (Resident 43), when the physician's order for oxygen administration was not followed. This failure had the potential to result in ineffective oxygen therapy, respiratory distress, and decline in the resident's health condition. Findings: On February 25, 2025, at 10:59 a.m., Resident 43 was observed in bed with oxygen (O2) via nasal cannula (NC - a tube used to deliver oxygen through the nose). Resident 43's oxygen administration was observed at 4 liters per minute (LPM). On February 27, 2025, at 10:33 a.m., a concurrent observation, interview and record review was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 confirmed the O2 level for Resident 43 was at 4 LPM. LVN 1 verified the physician order and stated the O2 level should be at 2 LPM, as per physician's order. LVN 1 stated the physician's order was not followed. On February 27, 2025,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities during the monthly Medication Regimen Review (MRR) for one of six randomly selected residents (Resident 58) when the facility did not clarify the physician's order for Vitamin D3 (a type of Vitamin supplement). This failure had the potential for Resident 58 to receive a wrong dose of Vitamin D3. Findings: During the medication administration observation on February 25, 2025, at 9:57 a.m. with licensed vocational nurse (LVN) 3, LVN 3 was observed preparing seven medications for Resident 58. During the medication preparation process, LVN 3 did not administer Vitamin D3 and stated Resident 58's Vitamin D3 order did not have a strength (the amount of medication) indicated. LVN 3 stated she needed to clarify the order. A review of the Resident 58's admission Record, dated February 27, 2025, indicated, Resident 58 was admitted on [DATE], with diagnoses that included, chronic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 therapeutic menu was followed for two residents, a sampled resident 66, and unsampled resident 17, on renal diets (a diet to protect the health of the kidneys). These failures led to the two residents receiving foods that did not meet their nutritional needs and may have further compromised their health status. The facility census was 72. Findings: Review of Resident 17's admission Record dated 2/28/25 indicated Resident 17 was admitted on [DATE] and readmitted on [DATE] to the facility with diagnoses that included COPD (chronic obstructive pulmonary disease- difficulty breathing due to obstruction in the lungs), CKD (chronic kidney disease- inability of the kidneys to effectively filter wastes) and HLD (hyperlipidemia- high levels of fat in the blood). Review of Resident 17's minimum data set (MDS- standardized assessment tool used to assess and monitor resident health status, functional capabilities, and needs) 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 observation, interview, and record review, the facility failed to implement their policy and procedure regarding food brought in from the outside, when one resident (Resident 66), who had a diagnosis of diabetes (chronic condition characterized by high blood sugar), had chocolate candies inside of his nightstand drawer that were brought in from the outside. This failure had the potential for Resident 66 to be non-compliant with the prescribed diet leading to high blood sugar. Findings: On February 25, 2025, at 8:32 a.m., an observation with a concurrent interview was conducted with Resident 66. Resident 66 was observed alert and conversant, Resident 66 was sitting on edge of the bed next to his nightstand. The nightstand drawer was observed to be open and inside were bite size chocolate candies. Resident 66 stated his family member brought in the chocoate candies and the staff were aware of it. On February 25, 2025, at 5:12 p.m., Resident 66's record was reviewed. Resident 66 was admitted to 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 observations, interviews, and document reviews, the facility failed to ensure the physician's progress notes in the medical records were accurately completed for a sampled resident (Resident 673) and unsampled resident (Resident 3) with significant weight loss for the past one month. This failure had the potential to negatively impact health and nutrition status and lead to further decline of the two residents with significant weight loss. The facility census was 69. According to the April 10, 2010, Proceedings of the SIGCHI Conference on Human Factors in Computing Systems article Physician-Driven Management of Patient Progress Notes in an Intensive Care Unit; .A patient progress note is a clinical document, written by a .physician, describing a patient's status and the physician's assessments and care plan for the patient. An attending physician, who has primary responsibility for the patient's care, composes a daily note for each of their patients. These notes are referred to by other clinicians as…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 environment was free of accident hazards when one of 74 residents had a shotgun, two airsoft guns, and a chainsaw in his room (Resident 1). This failure resulted in Resident 1 having access to his shotgun, airsoft guns, and chainsaw, and could have resulted in mental anguish for the other residents in the facility, accidents or death. Findings: On February 4, 2025, at 9:35 a.m., an unannounced visit was made to the facility to investigate two anonymous complaints about residents ' safety. On February 4, 2025, at 12:15 p.m., the Director of Nursing (DON) was interviewed. The DON stated Resident 1 ' s room was cleaned on January 28, 2025, while the resident was at the hospital. The DON stated two airsoft guns, a chainsaw, and a shotgun (unloaded) were found in his room. The DON stated the local Police were notified and they took custody of the two airsoft guns and the shotgun (which was registered in his name). The DON stated Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure for two of three residents, Residents 1 and 2, the plan of care was reviewed and updated after Residents 1 and 2 attempted to elope (when a patient leaves a healthcare facility without supervision or detection while they are unable to protect themselves) from the facility. This failure resulted in Resident 1 eloping from the facility on November 18, 2024, and had the potential to result in Resident 2 eloping from the facility. Findings: On November 5, 18, and 19, 2024, unannounced visits were conducted at the facility to investigate complaint allegations. On November 18, 2024, a review of Resident 1's medical record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included dementia (loss of cognitive functioning, such as thinking, remembering, and reasoning, that interferes with daily life). A review of Resident 1's History and Physical dated May 6, 2024, indicated Resident 1 can make needs known but cannot make…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to protect resident rights for dignity and respect for two of six sampled residents (Residents 1 and 2) when both residents were addressed in a disrespectful manner by a Certified Nurse Aide (CNA) 4. This failure had the potential to cause psychosocial harm and emotional distress to Resident 1 and Resident 2. Findings: On October 3, 2024, 5:05 a.m., an unannounced visit was conducted at the facility to investigate allegations of potential abuse and resident rights. A review of Resident 1's admission record indicated Resident 1 was initially admitted to the facility on [DATE], and re-admitted on [DATE]. Resident 1's diagnoses included a disorder of the brain, altered mental status (disorders and injuries that affect brain function), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), type 2 diabetes (a long-term condition in which 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 the personal privacy of one of six sampled residents (Resident 4) when a visitor unknown to the resident was allowed into the resident's room. This failure caused emotional distress to Resident 4 and put the resident's safety at risk. Findings: On October 3, 2024, 5:05 a.m., an unannounced visit was conducted at the facility to investigate allegations of resident safety. A review of Resident 4's admission record indicated she was admitted to the facility on [DATE]. Resident 4's diagnoses which included fracture of right femur (the only bone in the thigh), repeated falls, difficulty walking. A review of Resident 4's Minimum Data Set (MDS – a standardized comprehensive assessment and care planning tool) dated October 2024, indicated Resident 4's BIMS (brief interview for mental status, ranges from 0 to 15) score was 15, which indicated the resident was cognitively intact. A review of Resident 4's History and Physical dated August 3,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 alleged abuse involving two of six sampled residents reviewed (Residents 1 and 2) were reported to the California Department of Public Health (CDPH) immediately or within two hours of the facility being aware of the alleged abuse. This failure had the potential to result in a delayed investigation of the alleged abuse causing a delay in implementation of corrective actions which placed the residents at risk for further abuse. Findings: On October 3, 2024, 5:05 a.m., an unannounced visit was conducted at the facility to investigate allegations of potential abuse and resident rights. A review of Resident 1's admission record indicated Resident 1 was initially admitted to the facility on [DATE], and re-admitted on [DATE]. Resident 1's diagnoses included a disorder of the brain, altered mental status (disorders and injuries that affect brain function), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 3) was supervised and interventions were put in placed to prevent elopement (leaving the facility without the staff's knowledge). This failure resulted in Resident 1 eloping from the facility and had the potential to cause injury and harm to the resident. Findings: On October 3, 2024, 5:05 a.m., an unannounced visit was conducted at the facility to investigate the elopement of a resident. A review of Resident 3's facility admission record indicated Resident 3 was admitted to the facility on [DATE], at 6:25 p.m. with a diagnosis of lumbar fracture (a break in the lower back spine that can cause moderate to severe back pain). There was no photograph of the resident on the admission record. A review of Resident 3's medical record titled Elopement Evaluation, dated October 1, 2024, at 8:22 p.m. indicated the resident had verbally expressed the desire to go home. A review of Resident 3's care plan…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 promote care that maintained the dignity and respect for one resident (Resident 1), when he was told by facility staff to stop turning his f (expletive) call light on if he wanted to be left alone. This failure had the potential to affect Resident 1's psychosocial well-being. Findings: On July 30, 2024, at 12:00 p.m., an unannounced visit to the facility was made to investigate a complaint. Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease (COPD- a lung disease that causes restricted airflow and breathing difficulties), asthma, and depression (a mood disorder that causes a persistent feeling of sadness). A review of Resident 1's Progress Notes , dated July 28, 2024, indicated, Resident 1 was experiencing shortness of breath and called 9-1-1 (emergency services) for an ambulance. The LVN offered the resident a rescue inhaler and a breathing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of three residents reviewed (Resident 4) was assessed, monitored, and supervised to prevent elopement (leaving the facility without permission). This failure resulted in Resident 4 eloping from the facility and had the potential to cause injury and harm to the resident. Findings: On July 30, 2024, an onsite visit was made to the facility to investigate a complaint regarding the elopement of Resident 4. A record review for Resident 4 indicated Resident 4 was admitted to the facility on [DATE], with diagnoses which included Alzheimer's Disease (a brain disorder that slowly destroys memory and thinking skills). A review of Resident 4's Progress Notes dated July 29, 2024, indicated, Resident 4 was alert and verbally responsive, was seen walking through the hallways, with episodes of wandering and confusion. A review of Resident 4's Brief Interview of Mental Status (BIMS - an assessment tool), noted as In Progress , indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain temperatures between 71 to 81 degrees Fahrenheit (F) when resident room temperatures in two of eight sampled resident rooms, reached 82.9 degrees F and one of one sampled common area room (activity room) was 81.5 degrees F. This deficient practice resulted in discomfort for two of seven sampled residents (Residents 1 and 2), and potential adverse health effects for residents, staff and visitors including dehydration (loss of body fluids), heat stress (a series of conditions where the body is under stress from overheating), and heat stroke (when the body can no longer control its temperature). Findings: An unannounced visit was conducted on July 8, 2024, at 10:47 a.m. to investigate a complaint related to the facility's physical environment. On July 8, 2024, at 3:52 p.m., an observation and concurrent interview was conducted with Resident 1. Resident 1 was observed sitting on the side of her bed near the window with the curtains…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the resident ' s representative with requested financial documents within 48 hrs. after request was made, for one of three sampled residents (Resident 1). This failure has the potential to result in missed payment which could negatively impact the resident or the resident's representative's financial standing. Findings: On June 13, 2024, an unannounced visit was made to the facility to investigate a financial billing issue. A review of Resident 1 ' s face sheet, dated May 17, 2024, indicated the resident was admitted to the facility on [DATE], with diagnoses which included respiratory failure, and was discharged from the facility on January 6, 2024. A review of Resident 1 ' s Brief Interview for Mental Status (Cognitive assessment) score of 99, which meant the resident was severely cognitively impaired. On June 13, 2024, at 10:46 a.m., an interview was conducted with the Business Office Assistant (BOA). The BOA stated 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 physician for one of three sampled residents (Resident 1) when: 1. The physician was not notified regarding Resident 1's change in treatment plan after the resident refused emergency room evaluation after experiencing a fall; and 2. The physician was not notified until the following day after Resident 1 sustained a fall. This failure had the potential to jeopardize the health and safety of Resident 1. Findings: 1. A review of Resident 1's admission record indicated the resident was admitted to the facility on [DATE], readmitted [DATE], and discharged on March 22, 2024, with diagnoses that included hemiplegia (paralysis) & hemiparesis (weakness) on the left side, difficulty walking, and history of falling. A review of Resident 1's Health Status Note dated February 24, 2024, at 11:50 pm, by Licensed Vocational Nurse (LVN)1 indicated the resident sustained a fall and was assessed for injuries, altered mental status, and pain. The note further…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a safe environment according to their fall management policy and procedure for one of three sampled residents when: 1. The facility did not conduct an Inter-disciplinary Team (IDT) meeting to determine the root cause of Resident 1's fall on February 24, 2024; and 2. The facility did not accurately assess Resident 1's fall risk after the resident sustained a fall on March 20, 2024. This failure had the potential to result in further falls and harm for Resident 1. Findings: 1. A review of Resident 1's admission record indicated the resident was admitted to the facility on [DATE], readmitted [DATE], and discharged on March 22, 2024, with diagnoses that included hemiplegia (paralysis) & hemiparesis (weakness) on the left side, difficulty walking, and history of falling. A review of Resident 1's Health Status Note dated February 24, 2024, at 11:50 pm, by Licensed Vocational Nurse (LVN) 1 indicated the resident sustained a fall and was assessed for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed, for one of four sampled residents reviewed (Resident 1) to ensure two bottles of oral nutritional supplements (health supplement) had a physician's order and were not stored by the bedside. This failure had the potential to result in incorrect self-administration of medication by Resident 1 and unauthorized access of other residents and staff to the medication. Findings: On March 26, 2024, at 11:05 a.m., an observation with a concurrent interview was conducted with Resident 1. Resident 1 was in his room sitting on his bed. Observed on the top of his bedside table were two bottles (one opened and one unopened) of nutritional supplements labeled as Juice Plus (brand name of nutritional supplement). In a concurrent interview, Resident 1 stated the two bottles of nutritional supplements were his and he had been taking them. On March 26, 2024, Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses 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 provide bed hold notification for one of three sampled residents (Resident 1) prior to discharge to acute care. This failure had the potential result in Resident 1 not being able to return to the facility after discharged from acute care. Findings: A review of Resident 1's admission record indicated the resident was admitted to the facility on [DATE], with diagnoses that included sepsis (the body's extreme response to infection), end stage renal disease, and dependence on dialysis. The record indicated the resident was discharged on February 23, 2024. A review of Resident 1's discharge summary note dated February 23, 2024, at 10:50 am by Licensed Vocational Nurse (LVN1) indicated, Patient sent to ER per MD for discoloration on left amputation (amputation) site. Transportation services picked up pt via wheelchair at 1045 hrs. On March 13, 2024, at 3:30 p.m., during an interview with the Administrator (ADM), he stated the facility's practice is if…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to report an allegation of abuse for one of three sampled residents (Resident 3) to the California Department of Public Health (CDPH), immediately but not later than 2 hours after the allegation was made. The facility was made aware of the allegation on January 4, 2024. This failure had the potential to result in a delay of investigation and reporting of further allegations of abuse. Findings: On January 9, 2024, at 3:26 p.m., CDPH received a five-day investigation report from the facility of an allegation of abuse that occurred on January 4, 2024. CDPH had not received an initial reporting of an abuse allegation prior to receiving the five-day investigation report from the facility on January 9, 2024. On January 17, 2024, at 8:32 a.m., an unannounced visit was made to the facility for the investigation of the incident regarding the alleged abuse. On January 17, 2024, Resident 3 ' s facility medical record was reviewed. Resident 3 was admitted to 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 follow their policy and procedure when staff did not wear face masks during a covid-19 (coronavirus- infectious agent) outbreak in the facility. This failure had the potential to infect staff and residents with an infectious agent (COVID-19). Findings: On November 21, 2023, during an observation, signs posted on the front door encouraging visitors to wear face masks. The facility noted to have a notification of positive covid cases in the resident population posted on the front door. On November 21, 2023, at 1:53 p.m., during a concurrent observation and interview with Licensed Vocational Nurse (LVN1), LVN1 noted wearing a N95 mask (a mask worn to filter airborne infectious agents). She stated the facility's covid cases began at the end of October as a staff member tested positive. She stated the facility placed all the covid positive residents in the first several rooms in the facility beginning with room [ROOM NUMBER]. room [ROOM NUMBER]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately re-imburse the resident ' s funds, for one of four residents reviewed (Resident 1). When Resident 1 ' s social security (SS) payment was inadvertently deposited into another resident ' s account and an audit was not conducted to verify the exact amount of Resident 1 ' s re-imbursement. This failure had the potential for a misappropriation of funds to occur. Findings: On December 4, 2023, at 4:05 p.m., a telephone interview was conducted with Resident 1 ' s representative (RR). The RR stated Resident 1 ' s SS payment was deposited into the wrong account and the facility failed to re-imburse him the correct amount. On December 12, 2023, at 11:05 a.m., an unannounced visit was conducted at the facility to investigate the above allegation. On December 12, 2023, Resident 1 ' s record was reviewed. Resident 1 was admitted to the facility on [DATE], and discharged on August 27, 2022, with diagnoses which included syncope (sudden loss 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 one of three sampled residents (Resident 1) was supervised and interventions were put in place to prevent elopement (leaving the facility without the staff's knowledge). This failure resulted in Resident 1 eloping from the facility and had the potential to cause injury and harm to the resident. Findings: On September 29, 2023, a review of Resident 1's record indicated Resident 1 was admitted to the facility on [DATE], with a diagnosis of metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), hepatic encephalopathy (when toxins that are normally cleared from the body by the liver accumulate in the blood, eventually traveling to the brain), and alcoholic cirrhosis of liver (an advanced stage of alcoholic liver disease that causes your liver to become stiff, swollen, and decreases liver function). The Minimum Data Set (MDS - an assessment tool) dated September 19, 2023, indicated a Brief…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was supervised and interventions were put in place to prevent elopement (leaving the facility without the staff's knowledge). This failure resulted in Resident 1 eloping from the facility and had the potential to cause injury and harm to the resident. Findings: A review of Resident 1's admission record dated July 12, 2023, indicated, Resident 1 was admitted to the facility on [DATE], on hospice care (end of life care) with a diagnosis of malignant neoplasm of the rectum (cancer). The Minimum Data Set (MDS - an assessment tool) dated March 20, 2023, indicated, a Brief Interview for Mental Status (BIMS) of 15 out of 15 indicating no memory impairment. A review of the document titled, Progress Note, dated July 8, 2023, indicated, at 12:00 p.m., a Certified Nursing Assistant (CNA) notified the charge nurse that Resident 1 could not be found. The charge nurse and the CNA looked in every room…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to transfer one of three sampled residents (Resident 1) to acute care for evaluation per physician order. This failure resulted in Resident 1 experiencing a delay in treatment. Findings: A review of Resident 1's admission record indicated the resident was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with diagnoses which included hip fracture, repeated falls, and diabetes mellitus (inability to control blood sugar). The record further indicated the resident was her own representative. A review of Resident 1's Brief Interview for Mental Status (BIMS) dated January 25, 2023, indicated the resident had a score of 13 (mild cognitive impairment). A review of Resident 1's change in condition evaluation dated February 8, 2023, at 5:05 pm indicated the resident had discoloration of lower extremities. The assessment indicated the physician was notified at 6:28 p.m. A review of Resident 1's health status note dated February 8, 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 interview and record review the facility failed to follow their policy and procedure for one of three sampled residents (Resident 1) when the facility did not provide wound care as ordered by the physician. This failure had to potential to cause wound progression and delayed healing for Resident 1. Findings: A review of Resident 1's admission record indicated the resident was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with diagnoses which included hip fracture, repeated falls, and diabetes mellitus (inability to control blood sugar). The record further indicated the resident is her own representative. A review of Resident 1's Brief Interview for Mental Status (BIMS) dated January 25, 2023, indicated the resident had a score of 13 (mild cognitive impairment). A review of Resident 1 ' s physician orders indicated an order for Sacro coccyx wound- cleanse with NS (normal saline), pat dry, apply Medi honey and cover with foam dressing every day shift dated December 29,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to follow their policy and procedure for falls for one of three sampled residents (Resident 1) when the facility did not conduct an interdisciplinary team (IDT) meeting for Resident 1 ' s fall. This failure had to potential to result in Resident 1 sustaining additional falls. Findings: A review of Resident 1's admission record indicated the resident was admitted to the facility on [DATE], and readmitted to the facility on [DATE] with diagnoses which included hip fracture, repeated falls, and diabetes mellitus. The record further indicated the resident is her own representative. A review of Resident 1's Brief Interview for Mental Status (BIMS) dated January 25, 2023, indicated the resident had a score of 13 (mild cognitive impairment). A review of Resident 1's section I dated January 25, 2023, indicated the resident had diagnoses of heart failure, hypertension (high blood pressure), diabetes mellitus (inability to regulate blood sugar), repeated falls. 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 establish a baseline weight for one of three sampled residents (Resident 1) when the resident was not weighed on admission in accordance with the facility policy and procedure. This failure had the potential for the facility not to identity weight loss or weight gain which could delay provision of appropriate intervention for Resident 1, a clinically-compromised resident. Findings: A review of Resident 1's admission record indicated the resident was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included subluxation (dislocation) of C1/C2 vertebrae, protein-calorie malnutrition, history of falling, and dementia (loss of cognitive function- memory, thinking, reasoning). A review of Resident 1's Brief Interview for Mental Status (BIMS) dated May 20, 2023, indicated the resident had a score of 8 (severe cognitive impairment). A review of Resident 1's weights indicated the following: May 16- 73 pounds (13 days after…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facility's policies and procedures were developed and implemented to track accurately the movement of controlled substances (CS) and to fully account for use of all CS in order to minimize the time and loss of diversion. The facility's system of controlled substance accountability was not able to identify missing blister cards containing CS during shift change auditing process between incoming and outgoing nursing staff. This had the potential for drug diversion by staff caring for the residents. Findings: Review of the facility's notification letter to the department dated, June 30, 2023, indicated: .This letter is a follow up to your office regarding the discrepancy of a controlled substance for [Resident 1] on Monday 6/23/2023 . As part of our investigation, the following were completed: - Three way audit of all narcotic count sheets - Pain assessment done for [Resident 1] . - Inservices and reeducation with Licensed Nurses initiated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, prepare, and distribute food in accordance with professional standards for food service safety when: a. Multiple food items were stored beyond their use by dates, readily available for use; and b. The ice machine was dirty. These failures had the potential to cause foodborne illnesses in medically vulnerable resident population who consumed food in the facility. The facility census was 69. Findings: On April 11, 2022, beginning at 10:15 a.m., a kitchen inspection was conducted with the Food and Nutrition Supervisor (FNS). The following were observed: a. 1. The following food items were stored inside the walk in refrigerator, readily available for use: - a half gallon [NAME] wine with a use by date of February 4, 2022; - one bunch of cilantro in a gallon freezer bag labeled with a received date of March 11, 2022, and a use by date of March 18, 2022; - two bunches of parsley in a gallon bag labeled with a received date of April 1,…

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

Based on observation, interview, and record review, the facility failed to ensure the licensed nurses documented by signing their names in the eMAR (electronic Medication Administration Record) after administering the controlled medications (such as narcotics - medications that dull the senses, relieve pain, treat seizures but in excess doses cause stupors, coma, or convulsions) to residents for pain and seizures for four of four residents reviewed (Residents 2, 34, 63, and 69) on multiple shifts and days in March and April 2022. This failure increased the potential for drug diversion (use of medication not intended by the prescriber). Findings: On April 13, 2022, at 11:02 a.m., a concurrent inspection of the medication cart, record review, and interview was conducted with Licensed Vocational Nurse (LVN) 2. Resident 69's PRN (as needed) narcotic pain medication, hydrocodone-APAP 5-325 (5 mg [milligram - a unit of measurement] hydrocodone [narcotic medication to relieve pain] and 325 mg acetaminophen [medication to relieve pain and fever]) every four hours as needed was not…

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

Based on observation, interview, and record review, the facility failed to ensure the Consultant Pharmacist (CP) identified irregularities in the use of medications for 12 of 12 residents reviewed (Resident 2, 10, 11, 19, 35, 40, 41, 48, 60, 63, 69, and 121) when: 1. The licensed nurses administered Vitamin D following duplicated physician orders to Resident 2; and 2. There was no documented evidence medications were administered to the residents for March 2022, and April 2022. In addition, the CP was not able to review the eMAR's (electronic Medication Administration Records) and did not make recommendations regarding nursing staff not documenting the medication administration on multiple shifts on multiple days. This failure had the potential to result in the residents' medications being used and not evaluated for possible identification of medication-related problems and complications the residents may have. Findings: 1. On April 12, 2022, at 9:20 a.m., a concurrent medication pass observation, interview, and record review was conducted with Licensed Vocational Nurse (LVN) 1. LVN…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, for 12 of 12 residents reviewed for unnecessary medications (Resident 2, 10, 11, 19, 35, 40, 41, 48, 60, 63, 69, and 121) there was no documented evidence the use of the medications were monitored for March 2022, and April 2022. This failure had the potential to result in the residents' medications being used and not evaluated for possible identification of medication-related problems and complications the residents may have. Findings: On April 14, 2022, at 10 a.m., the following residents' eMAR's (electronic Medication Administration Records) were reviewed. There was no documented evidence on multiple shifts on multiple days medications were monitored for the appropriate use for March 2022, and April 2022: 1. For Resident 2, the following medications required monitoring for March 2022, and April 2022: - furosemide (diuretic to remove fluid retention in the body) 40 mg (milligram - a unit of measurement) one tablet one time a day for edema (puffiness causes by fluid trapped in the body's tissues) hold (not…

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

Based on observation, interview, and record review, the facility failed to ensure the planned menu was followed for 21 of 21 residents with a physician ordered CCHO (Consistent Carbohydrate) diet (a diet used in the treatment for diabetes), when the residents received a full slice of lemon snow bar for dessert, instead of half a slice per the planned menu. Additionally, one resident on a low fat/low cholesterol diet received a full slice of the lemon snow bar for dessert instead of half a cup of fresh fruit. This failure had the potential to result in increased blood glucose levels for residents with a CCHO diet, and increased caloric intake for the resident on a low fat/low cholesterol diet. Findings: On April 13, 2022, at 11:00 a.m., an observation of lunch service was conducted. It was noted that 21 residents with a CCHO diet and one resident on a low fat/low cholesterol diet received a full slice of two inches by two and a half inches of lemon snow bar for dessert. A concurrent review of the document titled, SPRING CYCLE MENUS .Week 2 Wednesday .special spreadsheet salad day…

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

Based on interview and record review the facility failed to provide a written copy of the bed hold policy for transfers to the hospital for three of three residents reviewed for hospitalizations(Residents 60, 69, and 11). This failure had the potential for Resident 60, Resident 69 and Resident 11 to be uninformed regarding their right to request a bed hold while they were hospitalized . Findings: 1) On April 13, 2022, at 9:30 a.m., Resident 60's medical record was reviewed. Progress notes dated March 8, 2022, at 5:34 p.m., and March 17, 2022, at 11:02 p.m., indicated Resident 60 was sent to a local hospital for further evaluation. Resident 60's Bed Hold Agreement which indicated, .Notification of Bed Hold option upon transfer/therapeutic leave was blank. 2) On April 13, 2022, at 9:45 a.m., Resident 69's medical record was reviewed. A progress note dated March 24, 2022, at 5:24 p.m., indicated Resident 69 was sent to a local hospital for further evaluation. Resident 69's Bed Hold Agreement which indicated, .Notification of Bed Hold option upon transfer/therapeutic leave was blank. 3)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Resident 14 was up in a geriatric chair (geri-chair-a large, padded chair that is designed to help with limited mobility) daily as ordered by the physician. This failure could potentially result in a decline in Resident 14's activities of daily living (ADLs). Findings: On April 11, 2022, at 11:50 a.m., Resident 14 was observed asleep in bed, with a contracture (shortening and hardening of the muscles) to the right hand. Resident 14's legs were elevated on a pillow. On April 12, 2022, at 9:45 a.m., Resident 14 was observed lying flat in bed, with the head of bed slightly elevated. Resident 14 had a contracture to the right hand, and both legs were elevated on a pillow. Resident 14 was unable to move his arms and legs. At 10:46 a.m., Resident 14's family member (FM) was interviewed via telephone. The FM stated she was told Resident 14 was gotten up every other day, but she felt it would benefit Resident 14 more if the facility 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 follow their policy and procedure for safe smoking practices for one of one resident reviewed for smoking (Resident 35). This failure had the potential for increased risk for smoking related injuries for Resident 35. Findings: On April 11, 2022, at 10:51 a.m., a concurrent observation and interview was conducted with Resident 35. Resident 35 was observed in her room. Resident 35 stated she would smoke anytime, unaccompanied. Resident 35 stated she could smoke all the time and anytime she wanted to smoke. On April 12, 2022, at 9:05 a.m., Resident 35 was observed wheeling herself to the patio, unaccompanied. Resident 35 stated she was going out to smoke. Resident 35 was observed carrying her own smoking materials. No smoking supervision by facility staff was observed. On April 12, 2022, at 11:01 a.m., Resident 35 was observed in the patio area, sitting in her wheelchair, smoking, unsupervised. A schedule for smoking was observed posted 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 that there was a physician's order for the continued use of an indwelling Foley catheter (a flexible tube inserted into the bladder to provide continuous urinary drainage) for one of two residents reviewed for an indwelling catheter (Resident 37). This failure had a potential to result in unnecessary catheterization of Resident 37. Findings: On April 11, 2022, at 3:13 p.m., Resident 37 was seen in his bed. Resident 37 was observed to have a Foley catheter attached to a urinary leg bag (a smaller urinary drainage bag that can be used under the clothes). Resident 37 stated he had the urinary catheter inserted from the hospital before he was admitted to the facility. On April 12, 2022, Resident 37's record was reviewed. Resident 37 was admitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease (COPD-a condition involving the lungs resulting in difficulty or discomfort in breathing),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow current acceptable principles to label and store medications and biologicals (used to treat, prevent, and diagnose diseases and medical conditions) when: 1. A discontinued medication was stored in the medication cart, readily available to use. This failure increased the risk for the licensed nurses to administer discontinued medication to the residents which could result in medication and treatment errors; 2. An insulin pen was in use with no open date. This failure had the potential for licensed staff to administer the insulin to a resident past its expiration date; and 3. An antibiotic medication was missing in the original and unopened IV (Intravenous - administer fluids or medications via veins) E-Kit (Emergency Kit - an emergency storage box containing a small quantity of critical medications used in emergency situations). This failure had the potential to delay the treatment for residents. Findings: 1. On [DATE], at 9:20…

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