Premier Care Center For Palm Springs

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed ensure cigarettes and smoking paraphernalia were kept secured in a locked container in the nursing station, according to the plan of care and facility's policy and procedures, for one of two residents reviewed for smoking (Resident 123).This failure had the potential to place Resident 123 and other residents at risk of harm and injuries.Findings:On March 3, 2026, at 8:58 a.m., a concurrent observation and interview with Resident 123 was conducted in his room. Resident 123 stated his cigarettes and lighter were stored in his bag at the bedside. One box of cigarettes and one lighter were observed inside his gray bag on the bed beside him.A review of Resident 123's Face Sheet, indicated the resident was admitted to the facility on [DATE], with diagnosis which included need for assistance with personal care.A review of Resident 123's History and Physical Examination, dated February 26, 2026, indicated Resident 123 had the capacity to understand…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 essential items necessary for hydration were in reach, for two of two residents reviewed for hydration (Residents 12 and 17), when the residents' water pitchers were observed out of reach. This failure had the potential to result in compromised hydration, impaired skin integrity, and increased risk for falls.Findings: 1. On March 2, 2026, at 11:28 a.m., Resident 12's room was observed to have a water drop signage outside of the room labeled under the resident's name. Resident 12 was observed sitting in bed with head of the bed elevated, awake and alert. Resident 12 both forearms were observed to be dry. Resident 12's water pitcher was observed on the nightstand beside the upper part of the bed and was out of reach.On March 5, 2026, at 11:39 a.m., an interview was conducted with Certified Nurse Assistant (CNA) 5. CNA 5 stated the water drop signage by a resident's door would indicate either the resident is on fluid restriction or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure pain medications were administered according to the physician's order, for two of three residents reviewed under pain (Residents 12 and 62).This failure had the potential for Residents 12 and 62's pain not to be managed appropriately.Findings:On March 5, 2026, at 10:32 a.m., during an inspection of Medication Cart A conducted with the Infection Preventionist (IP), the narcotic box contained controlled medications.1.Resident 12 had a bubble pack of Hyrdocodone-Acetaminophen (controlled medication for pain) 5/325 mg (milligram - unit of measurement). Resident 12's record and narcotic count sheet was concurrently reviewed with the IP.A review of Resident 12's Face Sheet, indicated the resident was admitted to the facility on [DATE], with diagnoses which included heart failure.A review of Resident 12's Order Summary Report, included the following physician's order:- HYDROcodone-Acetaminophen.5-325 MG.1 (one) tablet.every 6 (six) hours as needed for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure required physician visits and ongoing medical oversight was conducted, for one of one resident reviewed (Resident 17), when there was no documented evidence of a physician visit for 2025. This failure had the potential to place the resident at risk for unidentified changes in medical condition, outdated treatment plans and medication-related complications. ce the resident at risk for unidentified changes in medical condition, outdated treatment plans and medication-related complications. Findings:On March 3, 2026, at 3:42 p.m., Resident 17's medical record was reviewed. Resident 17 was admitted to the facility on [DATE], with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (weakness or paralysis on the left side of body) and nutritional deficiency (when the body lacks essential vitamins or minerals needed for proper function).A review of Resident 17's Minimum Data Set (MDS- 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 interview and record review, the facility failed to ensure abnormal laboratory result was referred to the physician, for one of 23 residents reviewed (Resident 11), when the potassium (an essential mineral and electrolyte crucial for maintaining healthy blood pressure, heart function, nerve signals, and muscle contractions) level was 3.2 (normal range of 3.5 to 5.1).This failure had the potential for delayed care and treatment and could affect Resident 11's overall health condition.Findings:On March 5, 2026, Resident 11's record was reviewed. Resident 11's Face Sheet, indicated the resident was admitted to the facility on [DATE], with diagnoses which included muscle disorder.A review of Resident 11's physician order, dated January 7, 2026, indicated, .BMP (Basic Metabolic Panel (a laboratory test which measures eight different substances in your blood) 1/8/2026 (January 8, 2026).A review of Resident 11's Lab (laboratory) Results Report, dated January 8, 2026, indicated a potassium level of 3.2 mmol/L…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 fortified diet (having had vitamins or other supplements added to increase the nutritional value) was provided as ordered by the physician and according to the facility's diet menu spreadsheet, for one of 14 residents with fortified diet order (Resident 44).This failure had the potential for Resident 44 not to receive the required dietary nutrients and could lead to weight loss and affect overall health condition of the resident. Findings:On March 5, 2026, at 11 a.m., a tray line (food assembly) observation was conducted for the lunch meal service.During the temperature check of food items beginning at 11:45 a.m., some salad bowls were observed to have F marked on the plastic covers, which indicated these were fortified. The facility document titled, Diet Type Order, indicated Resident 44 had a fortified diet order.Resident 44's meal tray was observed to have the following: 1/2 (one-half) cup tossed green salad (covered, with no F…

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

Based on observation, interview, and record review, the facility failed to provide food at appropriate temperatures when served to the residents according to the facility's policy and procedure, for two of two residents (Residents 32 and 5), when the milk and salad's temperature were above the recommended temperature when served.This failure placed residents at risk to decrease their oral intake and affect the residents' nutritional status.Findings:On March 2, 2026, at 11:25 a.m., Resident 32 in B Wing (Rooms 11-24), was interviewed. Resident 32 stated meals were lukewarm.On March 3, 2026, at 9:11 a.m., Resident 5 in A Wing (Rooms 1-10), was interviewed. Resident 5 stated food was consistently cold.On March 5, 2026, during the lunch meal service, test tray was requested to determine serving temperature of food served to the residents in the facility. The test tray was placed inside the last meal cart at 12:53 p.m., which departed the kitchen at 12:55 p.m., arriving at A Wing at 12:58 p.m.On March 5, 2026, at 1:10 p.m., temperatures of the following meal items were taken and were 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 observation, interview, and record review, the facility failed to ensure the Infection Preventionist (IP) implemented the antibiotic stewardship program, for one of 93 residents reviewed (Resident 84), when the IP did not review multiple antibiotics that were prescribed for Resident 84. This failure had the potential to place Resident 84 at risk for complications related to prolonged antibiotic use, adverse drug reactions, and development of antibiotic-resistant organisms. Findings:On March 2, 2026, Resident 84's medical record was reviewed. Resident 84 was admitted to the facility on [DATE], with diagnoses which included cellulitis (serious bacterial infection of the deeper layers of skin and underlying tissue, often causing red, hot, swollen, and painful skin), and type 2 diabetes mellitus (a lifelong disease that occurs when your blood sugar is too high, which makes it difficult for your body to heal and easy for infections to start).A review of Resident 84's Minimum Data Set (MDS - a 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 influenza vaccine (an annual vaccine that protects against influenza [a contagious respiratory illness] by helping the body produce antibodies) was received after obtaining consent on January 26, 2026, according to the facility's policy and procedure, for one of five residents reviewed for immunization (Resident 88).This failure had the potential for Resident 88 to be at risk of acquiring influenza and increase the risk of experiencing complications related to it. Findings:On March 5, 2026, at 10:13 a.m., during an inspection of the medication refrigerator conducted with the Infection Preventionist (IP), one vial of influenza vaccine was found stored and labeled for Resident 88. The label indicated a pharmacy dispensed date of January 27, 2026.A review of Resident 88's record was conducted with the IP, which indicated the following:-Resident 88's Face Sheet, indicated the resident was admitted to the facility on [DATE];-Resident 88's 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 interventions to reduce the risk of falls were evaluated for effectiveness and modified to address multiple falls, for one of five residents reviewed (Resident A). This failure resulted in Resident A to experience multiple falls and had the potential for the resident to have repeat falls and sustain injury. Findings:On January 6, 2026, at 10 a.m., an unannounced visit to the facility was conducted for the investigation of quality of care.On January 6, 2026, at 11:50 a.m., a review of Resident A's medical record was conducted. Resident A was admitted to the facility on [DATE], with diagnoses which included cognitive communication deficit (an impairment in communication-speaking listening, reading-caused by disruptions in the cognitive process [mental activities] like memory and attention), syncope (fainting due to decreased blood flow to the brain), and collapse (falling).A review of Resident A's Progress Notes, dated June 21, 2025, at 10:07 a.m.,…

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

Based on observation, interview, and record review, the facility failed to ensure proper infection prevention and control standards was implemented to provide a safe and sanitary environment, when the HVAC (heating, ventilation, air conditioning) units filter were not changed according to the facility's policy and procedure and national infection control guidelines.This failure had the potential to result in residents who test positive for a respiratory disease to spread the illness to other residents in rooms which share the same ventilation system.Findings:On January 6, 2026, at 10:00 a.m., an unannounced visit was conducted at the facility for the investigation of a complaint about infection control.On January 7, 2026, at 3:15 p.m. an interview was conducted with the Infection Preventionist (IP). The IP stated the last COVID (a contagious respiratory illness) outbreak in the facility was in September 2025, and there were approximately 20 COVID positive residents and a few staff members. The IP stated the positive residents were placed on isolation precautions and transferred 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 to ensure environmental conditions were being monitored and maintained in a safe and functional manner for the residents and staff, when:1.The exit door was left open. This failure had the potential for the residents to get out of the facility without the knowledge of the facility staff. In addition, the maintenance shop door was left open and unattended. This failure had the potential for unauthorized staff and residents to have access to the the maintenance room and get materials that could have harm them or others; 2. The generator (used as a backup system if a facility loses electrical power) was not being tested according to the facility's policy and procedure. This failure had the potential for power to not be supplied to the facility in case of power outage; and3.The temperature of the water supplying the facility areas was not being monitored according to the facility's policy and procedure. In addition, the water temperature in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement infection control interventions and treatments to help decrease the spread of scabies (a contagious skin infestation caused by the microscopic mite, which burrows into the upper layer of skin to live and lay eggs, characterized by intense, nocturnal itching and a pimple-like rash), for one of five residents (Resident 1), when:1.The dermatologist's (a doctor who specializes in skin issues) orders for Permethrin (a topical medication to treat scabies) was not administered as ordered;2.The physician's order for skin scraping for scabies (involves a doctor or clinician taking a sample of skin from a burrow or rash using a scalpel or needle, mixing it with mineral oil on a slide, and examining it under a microscope to find mites, eggs, or fecal pellets for a definitive diagnosis) was not completed as ordered by the physician;3.The dermatologist's recommendation to place Resident 1 in contact isolation precautions ({CIP}-an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure an evaluation of elevated blood pressure and notification to the physician was conducted, for one of three residents reviewed (Resident 1). This failure had the potential for a delay in the care and treatment of Resident 1's uncontrolled hypertension (high blood pressure) and had the potential to experience complications related to high blood pressure. Findings:On July 22, 2025, at 8:25 a.m., during observation of medication pass conducted by Licensed Vocational Nurse (LVN) 1, LVN 1 was preparing medications for Resident 1. LVN 1 stated she checked Resident 1's blood pressure and was 171/70 mm HG (millimeters of mercury - a unit used to measure pressure, specifically blood pressure; normal blood pressure is 120/80). LVN 1 stated Resident 1 had a PRN (as needed) Clonidine (medication to treat high blood pressure) every eight (8) hours if more than 160. LVN 1 was observed to explain to Resident 1 the medications she prepared to be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, for one of three residents reviewed (Resident 1), the facility failed to ensure:1. A physician's order was obtained to discontinue or remove a urinary catheter prior to removal of the catheter; and 2. Monitoring and documentation of the resident's urine output, any signs and symptoms of pain and/or bladder distention, after the urinary catheter was removed. These failures had the potential for a delay in the care and treatment to address possible adverse effects from removal of the catheter. Findings: On July 22, 2025, at 8:22 a.m., an unannounced visit was conducted at the facility to investigate a quality-of-care issue. On July 22, 2025, at 8:32 a.m., Resident 1 was observed alert, oriented, and was lying in bed. In a concurrent interview, Resident 1 stated she had a urinary catheter (a flexible tube inserted into the bladder to drain urine) and the facility staff recently pulled it out. Resident 1 stated she had burning sensation when she urinated and was being given…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a complete pain assessment was conducted, which included the location of pain, for one out of three residents (Resident 1).This failure had the potential for Resident 1's pain not to be managed effectively. Findings:On July 22, 2025, at 8:22 a.m., an unannounced visit to the facility was conducted to investigate a quality-of-care issue.On July 22, at 8:32 a.m., an interview was conducted with Resident 1, who stated she had a urinary catheter (a long tube insert into the bladder to drain urine) and the licensed nurse pulled it out (removed/discontinued it). Resident 1 stated she still had burning sensation when she urinated. Resident 1 stated Tylenol (acetaminophen - a non-steroidal anti-inflammatory medication to relieve pain) helps the irritation and discomfort (resident pointed towards her bladder). Concurrently, Licensed Vocational Nurse (LVN) 1, asked Resident 1 what her pain rate was (on a scale from 1-10, 10 being the worst),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 proper monitoring and neurological assessments (used to monitor patients, checking mental status, nerves, reflexes and motor function) were completed, for one of three residents (Resident A). This failure had the potential to cause delay in care and treatment for Resident A following an unwitnessed fall. Findings: On May 5, 2025, at 9:15 a.m., an unannounced visit was made to the facility for the investigation of a complaint regarding quality of care. On May 5, 2025, at 10:30 a.m., a review of Resident A's medical record was conducted. Resident A was admitted to the facility on [DATE], with diagnoses which included cerebral infarction (an ischemic stroke-a condition where blood flow to the brain is interrupted, causing brain damage) and encephalopathy (brain disease which alters brain function or structure). Resident A had a change in condition, dated April 11, 2025, at 10:33 p.m., which indicated, .falls .monitor . A review of Resident A's…

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

Based on observation, interview, and record review, the facility failed to ensure, for five of five residents reviewed (Residents 1, 4, 5, 6, and 7) received medications timely, when Residents 1, 4, 5, 6, and 7 ' s scheduled 9 a.m. medications were administered to the residents passed the required timeframe. This failure had the potential for the residents to experience discomfort, and a delay in the intended therapeutic effect of the medications. Findings: On February 25, 2025, at 9:25 a.m., an unannounced visit was conducted at the facility to investigate a complaint regarding quality of care. On February 25, 2025, at 11 a.m., Resident 1 was observed sitting up on the edge of bed. In a concurrent interview, Resident 1 stated she had some missed medications in the past. Resident 1 further stated the main medication she cared about was her Ritalin (methylphenidate - medication to treat used to treat attention deficit hyperactivity disorder). On February 25, 2025, at 1:30 pm, a concurrent interview and record review was conducted with the Director of Staff Development (DSD), and…

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

Based on interview and record review, the facility failed to ensure a registered nurse (RN) was scheduled for eight consecutive hours in a 24-hour period for November 3, 10, 16, 23, 24, 30, 2024 and December 7, 8, 15, 21, 22, 29, 2024. This facility failure had the potential to result in delayed identification and treatment of life-threatening medical conditions thus compromising the health and safety of the vulnerable population in the facility. Findings: On January 27, 2025, at 8:53 a.m., an unannounced visit to the facility was conducted to investigate nursing services complain. On January 27, 2025, at 11:15 a.m., an interview ws conducted with the Director of Staff Development (DSD). The DSD stated there was an RN who worked during weekends and would be in the facility from 5 a.m. to 7 a.m, and would come back at around 3 p.m. (would work for about three hours). The DSD stated licensed vocational nurses (LVN) would handle issues in the facility while the RN was out, and would notify the Director of Nursing via telephone and would give instructions. The DSD was not aware 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 treat resident with respect and dignity when the staff failed to cover the urinary bag, for one of one resident reviewed (Resident 2). This failure increased the potential to negatively affect Resident 2's psychosocial wellbeing. Findings: On December 23, 2024, at 8:52 a.m., during a concurrent observation and interview with Resident 2 in his room, Resident 2's urinary catheter drainage bag was observed to be not covered with a dignity bag (used to cover urine collection bag) and was hanging below the level of bed. Resident 2 stated he was not comfortable if someone would see his pee. On December 23, 2024, at 8:54 a.m., during a concurrent observation and interview with the Licensed Vocational Nurse (LVN). The LVN stated the urinary bag was exposed and was not covered with a privacy bag. The LVN further stated, he will feel not comfortable if that was his bag and was not covered, It should have been covered. On December 23, 2024, Resident…

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

Based on observation, interview, and record review, the facility failed to ensure the call light (device that produce a tone and light) was available for the resident to use and call for assistance, for one of two residents reviewed (Resident 2). This failure had the potential to result in the resident being unable to call for staff assistance when needed. Findings: On December 23, 2024, at 8:20 a.m., an unannounced visit was conducted at the facility for the investigation of a complaint. On December 23, 2024, at 8:48 a.m., during a concurrent observation and interview with Resident 2 in his room, Resident 2 was observed with a metallic silver portable call bell on top of his overbed table. There was no call light wiring attached to the socket on the wall and there was no push button wire connected to it. In a concurrent interview, Resident 2 stated the call light system was broken and staff gave him a call bell and was placed on top of his over bed table. Resident 2 further stated he cannot press the bell because his arms were unable to move, I yelled if I need help, It so…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents was free from verbal abuse, for one of five residents reviewed (Resident 5), when the Certified Nurse Assistant Student (CNAS) called Resident 5 an inappropriate word. This failure had the potential for Resident 5 to experience emotional distress. Findings: On December 23, 2024, at 8:20 a.m., an unannounced visit was made to the facility to investigate one facility reported incident. On December 23, 2024, Resident 5's record was reviewed. Resident 5 was admitted to the facility on [DATE], with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (both medical conditions that cause weakness or paralysis on one side of the body). A review of Resident 5's History and Physical, dated December 5, 2024, indicated Resident 5 was mentally capable of understanding. A review of Resident 5 ' s eInteract Change in Condition Evaluation, dated December 19, 2024, indicated, .VERBAL…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 verbal abuse by a Certified Nursing Assistant Student (CNAS) towards a resident to the California Department of Public Health (CDPH) immediately or within 2 hours after the allegation was made, for one of five residents (Resident 5). This failure had the potential to result in further abuse for Resident 5, affecting the resident's emotional, and psychosocial well-being. Findings: On December 23, 2024, at 8:20 a.m., an unannounced visit to the facility was conducted to investigate an allegation of abuse. A review of Resident 5's record indicated, Resident 5 was admitted to the facility on [DATE], with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (both medical conditions that cause weakness or paralysis on one side of the body). A review of Resident 5's History and Physical, dated December 5, 2024, indicated Resident 5 was mentally capable of understanding. 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 report an allegation of verbal abuse by a Certified Nursing Assistant Student (CNAS) towards a resident to the California Department of Public Health (CDPH) immediately or within 2 hours after the allegation was made, for one of five residents (Resident 5). This failure had the potential to result in further abuse for Resident 5, affecting the resident's emotional, and psychosocial well-being. Findings: On December 23, 2024, at 8:20 a.m., an unannounced visit to the facility was conducted to investigate an allegation of abuse. A review of Resident 5's record indicated, Resident 5 was admitted to the facility on [DATE], with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (both medical conditions that cause weakness or paralysis on one side of the body). A review of Resident 5's History and Physical, dated December 5, 2024, indicated Resident 5 was mentally capable of understanding. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure nutritional care and services were provided, for one of three sampled residents reviewed (Resident 7), when the nutritional recommendations of the Registered Dietitian (RD) to address Resident 7's significant weight loss were not followed. This failure resulted to Resident 7 not receiving the interventions to address resident's weight loss. In addition, this failure had the potential to result for further weight loss on Resident 7. Findings: On December 23, 2024, at 8:20 a.m., an unannounced visit was conducted to investigate a complaint on quality of care concerns. On December 23, 2024, at 2:20 p.m., during a concurrent observation and interview with Resident 7 in her room, Resident 7 was observed lying in bed and was wearing a loose-fitting white shirt. Resident 7 stated she use to wear the same clothes and it was well fit before but now the shirt was loose a little bit. Resident 7 further stated, This shirt started to loosen up.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 address or update care plans with measurable goals and interventions to address gastrointestinal (GI) symptoms (nausea, vomiting, and diarrhea), for four of nine residents (Resident 1, 2, 6, 21). This failure had the potential for the staff not to be aware of the interventions implemented to address the residents' GI symptoms. Findings: On December 6, 2024, at 9:45 a.m., an unannounced visit was conducted at the facility for the investigation of a facility reported incident regarding infection control. 1. On December 9, 2024, a review of Resident 1 ' s medical record was conducted. Resident 1 was admitted to the facility on [DATE], with diagnoses which included nutritional deficiency and anemia (low blood cell count). A review of Resident 1 ' s Progress Notes, dated November 21, 2024, at 2:35 p.m., indicated, .Patient noted to have 3 (three) episodes of vomiting and C/O (complaint of) nausea .new orders for Zofran (medication to treat nausea and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure infection control practices to control and manage gastrointestinal outbreak (GI outbreak - occurs when there are more cases of vomiting or diarrhea than expected in a given place or time) according to the facility's policy and procedure and CDC (Centers for Disease Prevention and Control) guidelines were implemented, when: 1. The facility staff did not perform hand hygiene after having contact with high-touch areas; 2. The facility staff did not wear the appropriate PPE (personal protective equipment - protective clothing or equipment designed to protect the wearer's body from infection) while providing care to a resident requiring Enhanced Barrier Precautions (EBP - a set of infection control measures that use of PPE to reduce the spread of infections); and 3. The facility did not monitor residents with GI symptoms and conduct surveillance tracking of the residents with GI symptoms. As a result, the facility failed to identify a GI…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure an assessment for safe self administration of medication was conducted, for three of 21 residents (Residents 38, 42, and 77) when: 1. One opened bottle of 15 ml (milliliter - unit of measurement) eyedrops (medication that relieves eye irritation) was found on the overbed table of Resident 38; 2. One opened respiratory inhaler medication (a handheld device that delivers medication directly to the lungs through breathing) of albuterol HFA (brand name) 108 mcg/act (microgram/actuation - unit of measurement) was found on the overbed table of Resident 42; and 3. One opened glass container of Muscle Balm pain relieving ointment (brand of ointment) 18 g (gram-unit of measurement) was found on the overbed table of Resident 77. These failures had the potential for Residents 38, 42, and 77 to receive multiple doses of medication without proper monitoring, which could lead to harmful effects. Findings: 1. On November 12, 2024, at 9:36 a.m.,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure, for three of 21 residents reviewed (Residents 28, 33, and 88): 1a. For Resident 28, the medication Lisinopril and Metoprolol (medications to treat high blood pressure) was not held according to the physician's order. In addition, the medication Midodrine (medication to treat low blood pressure) was not administered according to the physician's order. This failure had a potential for Resident 28 to have low blood pressure and could affect overall health condition; 1b. For Resident 28, there was no follow up assessment and monitoring after the resident was readmitted from the hospital on July 23, 29, and August 6, 2024. This failure had the potential for any changes in Resident 28's condition to be unidentified and could have a delay in the care and treatment; 2. For Resident 33, the discolorations on the forearms were not identified and monitored. This failure had the potential for Resident 33 to have complications related 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 ensure medications were administered as prescribed by the physician to meet the needs of the residents, when: 1. During a medication pass observation, a wrong dose of fluticasone (medication used for nasal congestion) nasal spray was administered, for one of five residents observed (Resident 65); 2. Four doses of an IV (intravenous; into vein) antibiotic medication was not administered in November 2024 without a reason documented in the medical record, for one of five residents reviewed (Resident 191); 3. For one of five residents reviewed (Resident 11), one blood pressure medication was held without properly documenting the reason for not administering the dose in accordance with the parameters ordered by the physician; 4. For one of five residents reviewed (Resident 3), two tablets of oxycodone (controlled substance for pain) were administered instead of one tablet for severe pain as ordered by the physician. These failures had 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 special dietary needs were provided, for three residents reviewed during the lunch meal preparation on November 15, 2024, (Residents 46, 76, and 192) . This failure had the potential to place residents at risk of not having their nutritional and dietary needs met. Findings: On November 15, 2024, beginning at 12:10 p.m., an observation of the lunch meal preparation was conducted. The steam table (a table having openings to hold containers of cooked food over steam or hot water circulating beneath them) was observed to have a 1/6 size 6-inch deep stainless steel pan containing pureed regular chili. Beside it was another 1/6 size 6-inch deep stainless steel pan containing pureed cornbread. On the right side, above the steam table, was a ¼ size 6-inch deep stainless steel pan containing pureed salad on ice. Behind the steam table, on the stove, was a 1/6 size 6-inch deep stainless steel pan containing pureed fortified chili. 1. The [NAME] placed one serving of pureed (food prepared in a blender to attain a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to store food in accordance with professional standards for food service safety, when multiple residents' food items were stored in the nurses' station refrigerator undated and out of date. This failure had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed these foods in the facility. Findings: On November 15, 2024, beginning at 3:30 p.m., the nurse's station refrigerator, which contained residents' food, was inspected with the Director of Nursing (DON). The following were observed: - One opened 24 oz (ounce- unit of measurement) tub of plain original yogurt was labeled with room [ROOM NUMBER]-B, and undated. In a concurrent interview, the DON stated the food item should have been dated when it was received, should not have been in the fridge anymore, and should be taken out; - One opened 500 ml (milliliter - unit of measurement) bottle of Coffeemate original creamer, was labeled with 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 observation, interview, and facility record review, the facility failed to maintain infection control practices when: 1. Resident 65 was observed in the dining room with his urinal hanging from the back of his wheelchair; and 2. One staff was observed not wearing the appropriate N95 respirator mask (disposable filtering device respirator) when providing care to COVID-19 (corona virus - a contagious respiratory disease) positive residents. These failures had the potential to spread infectious disease to other residents and staff in the facility. Findings: 1. On November 12, 2024, at 12:23 p.m., an observation was conducted in the dining room during lunchtime. Resident 65's urinal was observed hanging from the back of his wheelchair. A review of Resident 65's record indicated Resident 65 was admitted to the facility on [DATE] with diagnoses which included fracture (a break in the bone) of left foot and chronic kidney disease (long-term disease where kidneys are damaged and cannot filter properly). 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 the call light (device that produce a tone and light up indicating the location of the call, used by the residents to signal a need for assistance from facility staff) was answered promptly, for one of 93 sampled residents (Resident 9). This failure increased the potential for delayed nursing and medical management, as well as actual unmet care needs. Findings: On November 12, 2024, at 10:20 a.m., an observation with a concurrent interview was conducted with Resident 9 in his room. Resident 9's call light button was turned on because he wanted to request a refill his pitcher of fruit juice. Resident 9 stated he was not able to get assistance for 30 minutes, and usually happened during the morning shift. On November 12, 2024, at 10:25 a.m., Resident 9 was observed to press his call light and waited a staff to come to his room. There were two licensed nurses sitting at the nurse's station, talking while in front of the computer and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a copy of the Advance Directive (AD - a written instruction, such as a living will, relating to the provision of treatment and services when the individual becomes unable to decide) was available in the medical record, for one of seven residents reviewed for Advance Directives (Resident 11). This failure had the potential to result in Resident 11's wishes related to the provision of medical treatment and services to not be followed, if Resident 11 became unable to make decisions for himself. Findings: On November 14, 2024, Resident 11's record was reviewed. Resident 11 was admitted to the facility on [DATE], with diagnoses which included sepsis (a life-threatening condition that occurs when the body's immune system has an extreme response to an infection) and diabetes (abnormal blood sugars). A review of Resident 11's undated History and Physical indicated Resident 11 had the capacity to understand and make decisions. A review Resident 11'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 provide a safe and comfortable homelike environment, for one of six residents reviewed for environment (Resident 86) when the chair rail molding above the resident's bed was detached and damaged from the wall. This failure had the potential for Resident 86 to experience lack of sleep, discomfort, and irritability, which could affect the resident's overall health and well-being. Findings: On November 12, 2024, at 9:45 a.m., during a concurrent observation and interview with Resident 86 in his room, Resident 86 was observed sitting on his bed looking at the wall. Resident 86 stated he woke up early because he was not comfortable sleeping while a broken piece of wood was hanging above his head. Resident 86 further stated he was worried that if he raised up from the bed, he might hit his head to the wood. On November 13, 2024, at 11 a.m., Registered Nurse (RN) 1 was interviewed. RN 1 stted the broken chair molding should be reported 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 ensure, for one of one resident reviewed for ADL (Activities of Daily Living) was provided nail care (Resident 9). This failure prevented the resident from receiving maintaining proper grooming and personal hygiene. Findings: On November 12, 2024, at 9:46 a.m., Resident 9 was observed in his room with long yellowish, rough edged toenails growing outwards and were hypertrophied (thick). In a concurrent interview with Resident 9, he stated he asked the staff to trim his toenails and his request was ignored. Resident 9 stated he was not seen by the nail doctor to evaluate and trim his toe nails. He further stated, it looks like hawk nails. On November 12, 2024, at 10:51 a.m., Certified Nurse Assistant (CNA) 1 was interviewed. CNA 1 stated Resident 9 required total care and she had to do everything for him. CNA 1 stated she did not see Resident 9's long toe nals as she was in a hurry providing care to all the residents. She stated she would…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 proper storage of medications did not include unusable, expired medications when: 1. There were two expired daptomycin (antibiotic) IVPB (intravenous piggyback; a method of administering IV antibiotics by piggybacking it to a primary IV fluids) stored in the medication refrigerator for Resident 82; 2. There was one discontinued medication for Resident 35 in the medication cart along with other active medications; and 3. There was one injectable insulin (medication to control blood sugar) pen without an open date or expiration date in the medication cart. These failures had the potential for residents to receive expired and ineffective medications. Findings: 1. On November 12, 2024, at 11:30 a.m., during an inspection of the Medication Room with Registered Nurse (RN) 2, there were two IVPB daptomycin (antibiotic) 450 mg (milligram; unit of measurement) in normal saline 50 ml (milliliter; unit of measurement) bags labeled with, Discard after 11/9/24 (November 9, 2024), stored inside the 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 failed to provide a comfortable environment, for one of four residents (Resident 38) when water was leaking from the pipe under the sink, forming a puddle of water on the floor. This failure resulted in the resident feeling uncomfortable and disrupted the resident's daily living needs and environment. Findings: On November 13, 2024, at 9:10 a.m., during a concurrent observation and interview with Resident 38 in his room, a puddle of water was observed under the sink. Resident 38 stated the puddle of water came from the leaking pipe under the sink. Resident 38 stated he requested the staff to fix the pipe long time ago and until now it has not been resolved. Resident 38 further stated it was nasty every time the staff would use the sink, the water drips to the floor. On November 13, 2024, at 9:38 a.m., during an interview with the Maintenance Supervisor (MS), the MS stated he was not aware of the water leak in Resident 38's room. The MS stated if there was water on the floor, staff and residents might step on the wet…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the resident's meal intake was accurately documented, for one of three residents reviewed (Resident 1), when the facility did not document Resident 1's meal intake for multiple days. This failure had the potential to result in inaccurate nutrition assessments and a delay in the care and services to address nutrition issues for Resident 1. Findings: On March 1, 2024, at 11:30 a.m., an unannounced visit was conducted at the facility to investigate a quality of care issues. On March 1, 2024, Resident 1's records were reviewed. A review of Resident 1's admission record indicated the resident was admitted to the facility on [DATE], with diagnoses which included chronic systolic heart failure (heat disease) and nutritional deficiency. A review of Resident 1's Interdisciplinary Team Nutrition Updated, dated October 3, 2023, indicated the resident sustained a 6-pound weight loss or 4.6% weight loss in one week . A review of Resident 1's percent of meal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 changes in the residents's medication by hospice (a type of care that focuses on the palliation of a terminally ill patient's pain and symptoms and attending to their emotional spiritual needs at the end of life) was communicated to the facility for implementation, for one out of three sampled residents, when the order for albuterol sulfate inhalation (medication used to prevent and treat wheezing and shortness of breath caused by breathing problems) to be given every four hours routine was not carried out as ordered. This failure resulted to the resident not receiving the medication to aid in treating breathing problems and had the potential for the resident to not receive the full treatment to relieve him from breathing difficulty. Findings: On January 30, 2024, at 9:30 a.m., an unannounced visit was conducted at the facility to investigate two complaints on quality of care/treatment. On January 30, at 10:15 a.m., Licensed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 sufficient preparation for a safe orderly discharge on [DATE], for one (Resident 3) of five sampled residents. This failure increased the risk for Resident 3 not to receive the needed care and could result in rehospitalization. Findings: On January 8, 2024, at 10:00 a.m., an unannounced visit was conducted to investigate an Admission, Transfer and Discharge Right violation. On January 8, 2024, at 1:14 p.m., Licensed Vocational Nurse 2 (LVN) was interviewed regarding a resident who had recently been discharge from the facility. LVN 2 stated they have different department that should be handling the discharge planning so Resident 3 can be discharged safely, not alone. LVN 2 stated Resident 3 should have a support person available when she gets home. LVN 2 stated Case Manager (CM) and Social Services Director (SSD) should be the one following-up all the discharge plans and making preparation. On January 8, 2024, at 1:51 p.m., The SSD was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure: 1. Resident 1 was given pain medication (Norco/Hydrocodone Acetaminophen [combination medication is used to relieve moderate to severe pain]) in accordance with the physician order on December 19, 2023. This failure could have contributed to the resident being sedated which resulted in the resident's transfer to the general acute care hospital. 2. Resident 2 was given insulin in accordance with the physician order. In addition, the facility did not ensure a clear hypoglycemia management protocol was in place to address Resident 2's hypoglycemic episode on December 15, 2023. These failures have the potential to result in complication which can further worsen Resident 2's already compromised health condition. Findings: 1. On January 4, 2024, at 7:30 a.m., an unannounced visit was conducted to investigate allegations of quality care and treatment issues. A review of Resident 1's admission record indicated the resident was admitted to the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to reduce the risk of falls for one of three sampled residents (Resident 1) when the facility did not accurately assess the resident's risk of falls. This failure placed Resident 1 at risk for falls and jeopardized the health and safety of Resident 1. Findings: A review of Resident 1's admission record indicated the resident was admitted to the facility on [DATE], with diagnoses which included atherosclerotic heart disease, legal blindness, and history of falling. The record further indicated the resident was his own representative. The record indicated the resident was discharged on October 16, 2023. A review of Resident 1's fall risk evaluation dated October 5, 2023, indicated the resident was at low risk for falls. The evaluation indicated the resident had no falls within the past 3 months and the resident's vision was adequate. A review of Resident 1's Nursing note dated October 5, 2023, at 12:00 p.m. by Registered Nurse (RN1) indicated, This patient…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 rehabilitation services per physician order for one of three sampled residents (Resident 1) when the facility did not provide skilled therapy evaluations as ordered. This failure had the potential to result in Resident 1 to not maintain his highest level of function. Findings: A review of Resident 1's admission record indicated the resident was admitted to the facility on [DATE], with diagnoses which included atherosclerotic heart disease (narrow blood vessels), legal blindness, and history of falling. The record further indicated the resident was his own representative. A review of Resident 1's clinic records dated May 31, 2023, by [Physician] indicated on exam the resident was alert. No other reference to orientation. A review of Resident 1's nursing note dated October 5, 2023, at 12:00 p.m. by Registered Nurse (RN1) indicated, This patient is [AGE] year-old male .Patient admitted to [facility] for PT (physical therapy)/OT (occupational…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an advanced health care directive (ACHD) for one of three sampled residents when the facility allowed a resident, who had a healthcare agent, to self-discharge from the facility. This failure violated the rights of Resident 1's representative and had the potential to endanger the health and safety of Resident 1. Findings: A review of Resident 1's admission record indicated the resident was admitted to the facility on [DATE], and discharged on September 1, 2023, with diagnoses which included urinary tract infection, major depressive disorder, and hypertension. The record further indicated the resident was self-responsible. The record further listed the resident and her daughter as the resident's only contacts. On September 18, 2023, at 10:27 a.m., during an interview with the Director of Staff Development (DSD), she stated she has worked at the facility for 3.5 years. She stated family members or representatives are known by staff because they…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure an allegation of sexual abuse involving a resident (unknown) towards Resident A was reported to the California Department of Public Health (CDPH) immediately, or not later than two hours after the allegation was made. This failure had the potential to result in the delay in implementation of appropriate action and provision of protection to the resident and placed the resident at risk for further abuse. Findings: On July 28, 2023, at 9:45 a.m., an unannounced visit to the facility was conducted to investigate a facility reported incident regarding an allegation of sexual abuse. On July 28, 2023, at 9:55 a.m., an interview was conducted with the Administrator. The ADM stated he received report from Registered Nurse (RN) 1 via text message on July 27, 2023, at 5:42 a.m., indicating Resident A's report of another resident had touched his phone and blanket sometime on July 26, 2023. He stated on the morning of July 27, 2023, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure care and treatment was provided, for three of 18 residents reviewed (Residents 28, 34, and 175), when: 1. For Resident 28, the dark purple skin discoloration on the resident's left upper inner arm measuring approximately 6.8 centimeters (cm - unit of measurement) by (x) 9.5 cm in size was not identified and addressed; 2. For Resident 34, a skin infection on the resident's left middle finger was not identified and addressed; and 3. For Resident 175, there was no assessment conducted to evaluate the effectiveness of the Nystatin Suspension (medication used to treat oral thrush {fungal infection of the mouth}) after the treatment was completed on December 31, 2022. In addition, there was no care plan initiated to address the oral thrush. These failures have the potential to place these vulnerable residents at high risk for complications due to the delay of provision of care and treatment. Findings: 1. On January 9, 2023, at 3:40 p.m.,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure medications were administered as prescribed by the physician, for two of 18 residents reviewed (Residents 14 and 60), when: 1. For Resident 14, Midodrine (a medication used to increase blood pressure) was not held according to the physician's order; and 2. For Resident 60, pain medication was not administered according to the physician's order. These failures resulted to Residents 14 and 60 to receive medications inappropriately and had the potential for them to experience adverse effects. Findings: 1. On January 12, 2023, Resident 14's record was reviewed. Resident 14 was admitted to the facility on [DATE], with diagnoses which included seizures. The Medication Administration Record (MAR), for the months of December 2022 and January 2023, included a physician's order, dated October 2, 2022, which indicated, .Midodrine HCL Tablet 5 MG (milligram-a unit of measurement) Give 1 (one) tablet by mouth before meals for hypotension (low blood pressure)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 storage, preparation, and distribution of food were in accordance with professional standards for food service safety, when: 1. Kitchen areas, storages, and equipments were found with debris, discolorations, and residue; one storage room found with trash and one dead cock roach; and cooking utensils were found to have cracks and chips. 2. Resident's refrigerator was found to have food item and beverages that were not labeled accordingly. 3. A dietary staff was observed not practicing proper infection control when preparing food. These failures had the potential to result in cross contamination and foodborne illness (stomach illness acquired from ingesting contaminated food) in a medically vulnerable population of 66 residents who consumed food from the kitchen and the nourishment rooms out of a facility census of 70 residents. Findings: 1. On January 9, 2023, starting at 9:30 a.m., an observation of the facility kitchen and concurrent interview with the Dietetic Service Supervisor (DSS) was conducted.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a medication was received with a physician's order, for one of 18 sampled residents (Resident 63). This failure had the potential for Resident 63 to receive medication with no appropriate monitoring for medication effectiveness and side effects. Findings: On January 9, 2023, at 10:10 a.m., an observation with a concurrent interview was conducted with Resident 63. Resident 63 was observed sitting in bed, alert, and interviewable. Resident 63 was observed to have a bottle of PSYLLIUM Sugar-Free Powder Fiber (soluble fiber to ease constipation) 36.8 oz (ounce- unit of measurement) at her left bedside table. Resident 63 stated she had problems with constipation and the fiber supplement was brought by her family member before Christmas. Resident 63 stated the bottle of fiber powder was opened and she used it daily. Resident 63 stated she had asked the nurses to mix it with her water and she took it with Miralax (medication to treat…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure an eye consultation and/or referral to eye specialist was arranged and provided, for two of two residents reviewed for vision (Residents 62 and 28). This failure had the potential for the residents to experience a delay of treatment which may result in the decline of their eyesight. Findings: 1. On January 10, 2023, at 11:49 a.m., an observation with a concurrent interview was conducted with Resident 62. Resident 62 was observed in bed, alert, and interviewable. Resident 62 stated she needed eye glasses because she could not see clearly. On January 11, 2023, at 11:51 a.m., a concurrent interview and record review was conducted with the Minimum Data Set (MDS - an assessment tool) Nurse. The MDS Nurse stated Resident 62 was admitted to the facility on [DATE], with diagnoses which included hypertension (high blood pressure). The History and Physical, dated December 15, 2022, indicated Resident 62 did not have the capacity 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 interview and record review, the facility failed to ensure the psychotropic medication had an appropriate indication for use, for one out of five residents reviewed for unnecessary medications (Resident 14). In addition, the facility failed to monitor a specific behavior related to the use of the psychotropic medication for Resident 14. This failure had the potential for Resident 14 to receive unnecessary medication. Findings: On January 12, 2023, Resident 14's record was reviewed. Resident 14 was admitted on [DATE], with diagnoses which included psychosis (a mental disorder) and bipolar disorder (a mood disorder). The care plan, dated October 11, 2022, indicated, .Psychotropic (medications to treat mental disorders) medications use r/t (related to) PSYCHOSIS M/B (manifested by) MOOD DISORDER .Interventions .Monitor/record occurrence of for (sic) target behavior symptoms: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others .and document…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medication was stored according to the facility's policy and procedure, for one of 70 residents (Resident 377), when one packet of Thera Body Calazinc Body cream (medicated cream used to treat skin irritations, also used as a skin protectant) was found unsecured on top of the resident's overbed table. This failure increased the possibility for Resident 377 to receive medication unsafely and had the potential for other residents to have access to the medication and administer it unsafely. Findings: On January 9, 2023, at 4:07 p.m., Resident 377 was observed lying in bed with eyes closed. On top of his overbed table was one packet of Thera Calazinc Body Shield cream beside an empty medicine cup. On January 9, 2023, at 4:13 p.m., Resident 377 was observed with Licensed Vocational Nurse (LVN) 2. LVN 2 confirmed the presence of the Calazinc packet on Resident 377's overbed table. LVN 2 stated Resident 377 had an order for the Calazinc…

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

Based on observation, interview, and record review, the facility failed to ensure the food service personnel safely and effectively carried out the functions of food and nutrition service, when the Dietary Aide (DA) did not follow the manufacturer's recommended timeframe for testing the Quaternary ammonium (Quat) sanitizer solution (sanitizer solution used for removing bacteria and viruses in the kitchen). This failure had the potential for the Quat solution to not be tested within the right concentration level and could cause foodborne illness (stomach illness acquired from ingesting contaminated food), for 66 out of 70 sampled residents who received food from the kitchen. Findings: On January 9, 2023, at 11:44 a.m., a concurrent observation and interview with the Dietetic Service Supervisor (DSS) and Dietary Aide (DA) were conducted. The DA was observed to perform testing of the Quat solution twice by dipping the Quat test strip into the red bucket containing Quat solution. The DA dipped the Quat test strip in the Quat solution for four (4) seconds on the first attempt and five…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents' food preferences were honored, for two of 66 sampled residents (Residents 275 and 70), when: 1. Resident 275 was served milk despite the meal tray ticket indicating no milk to drink; and 2. Resident 70 was not served double portion of vegetables as requested. These failures had the potential to result in decreased food intake, and further compromising Resident 70 and 275's nutritional and medical status. Findings: 1. On January 9, 2023, at 12:20 p.m., a concurrent dining observation and interview was conducted with Resident 275 and Resident 275's family member (FM) in the dining room. Resident 275's meal tray was observed to have milk on it. The meal ticket was observed on the meal tray which indicated, Standing Orders .4 (four) fl oz (fluid ounces - unit of measurement) Milk Whole .Dislike .No milk to drink . Resident 275's FM stated, My husband is somewhat lactose intolerant. He absolutely could not drink milk and eat ice cream. I already told the dietitian. I do not know why they keep…

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