Foothill Heights Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide nutritional care and services for one (1) of two (2) sampled residents (Resident 44) reviewed for nutrition by failing to monitor and document the resident's meal intake in accordance with the care plan.This deficient practice had the potential to place Resident 44 at risk for further weight loss and negatively affect the resident's overall wellbeing. Findings:During a review of Resident 44's admission Record, the admission Record indicated Resident 44 was originally admitted to the facility on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities), dysphagia (difficulty swallowing), gastro-esophageal reflux disease (GERD - chronic digestive disease where the contents of the stomach refluxes and irritates the esophagus), and metabolic encephalopathy (a broad term for brain dysfunction caused by systemic illness, chemical imbalances, or organ failure rather than direct physical injury). During a review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 5) reviewed for tube feeding received gastrostomy tube (GT, a tube inserted through the belly that brings nutrition directly to the stomach) feeding on 5/4/2026 in accordance with the physician's order. This failure had the potential to cause preventable malnutrition (lack of proper nutrition in the body) and/or weight loss for Resident 5.Findings: During a review of Resident 5's admission Record, the admission Record indicated the facility initially admitted Resident 5 on 10/22/2018 and was readmitted on [DATE] with diagnoses that included but not limited to protein calorie malnutrition (a severe life threatening condition caused by a lack of enough calories and protein in the diet resulting in weight loss, weak immunity, and reduced functional capacity), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide the necessary respiratory care services for one of one sampled resident (Resident 11) reviewed for oxygen by failing to ensure oxygen (O2- a colorless, odorless, and tasteless gas essential for the survival of living things which use it for breathing and respiration) was administered to Resident 11 via nasal cannula (NC- a small plastic tube, which fits into the person's nostrils for providing supplemental O2) according to the physician's order. This deficient practice placed Resident 11 at risk for experiencing complications such as respiratory distress (a condition that occurs when the body needs more O2, resulting in difficulty breathing, rapid breathing, and low blood O2 levels) that can lead to serious illness and/or death.Findings: During a review of Resident 11's admission Record, the admission Record indicated the facility initially admitted Resident 11 on 8/6/2024 and readmitted on [DATE] with diagnosis including, but 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide trauma-informed care (an approach to delivering care that involves understanding, recognizing, and responding to the effects of all types of traumas) for one of two sampled resident (Resident 8) reviewed for behavior and diagnosed with post-traumatic stress disorder (PTSD, a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event).This deficient practice had the potential for Resident 8 to experience re-traumatization, (unintentionally causing harm through practices, policies, and/or activities that are insensitive to the needs of the residents) that could lead to severe psychosocial (dynamic intersection between psychological aspects [thoughts, emotions, and behaviors] and social factors [cultural, environmental, and interpersonal relationships]) harm and negatively affecting his quality of life.Findings:During a review of Resident 8's admission Record, the admission record indicated Resident 8…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 pharmaceutical services for one (1) of six (6) sampled residents (Resident 42) observed for medication administration by failing to ensure Licensed Vocational Nurse 5 (LVN 5) administered Carvedilol (medication used to treat hypertension [high blood pressure] and congestive heart failure [CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling]) with food on 5/5/2026 to Resident 42 as indicated on the physician's order and facility policy. This deficient practice had the potential for Resident 42 to experience gastrointestinal discomfort, nausea, and the risk for side effects such as dizziness, fainting, and sudden low blood pressure.Findings:During a review of Resident 42's admission Record, the admission Record indicated Resident 42 was admitted to the facility on [DATE], with diagnoses that included type 2 diabetes (a disorder characterized by difficulty in blood sugar…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Medication Cart 1 remained locked while unattended during medication administration on 5/5/2026 as indicated in the facility's policy. This deficient practice had the potential for unauthorized access to medications by residents, staff and visitors which could lead to medication overdose (taking a toxic or poisonous amount of a drug or medicine), unauthorized use, adverse reactions (any unexpected or dangerous reactions to a drug), or harmful drug interactions (a reaction between two or more drugs or between a drug, and a food, beverage, or supplement).Findings: During an observation on 5/5/2026 at 3:48 PM in the facility hallway, Medication Cart 1 was observed unlocked and unattended while Licensed Vocational Nurse 5 (LVN 5) was inside Resident's Room A. During an observation on 5/5/2026 at 4:22 PM, in the facility hallway, Medication Cart 1 was observed unlocked and unattended while LVN 5 was inside Resident's Room B. During an interview on 5/5/2026 at 4:57 PM with LVN 5, LVN 5 stated that per…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 (1) of two sampled residents (Resident 1) with history of attempted elopement (occurs when a resident leaves a facility without authorization or supervision) was provided safety protocols, supervision and ensure monitoring to prevent elopement when the front door was left unsupervised on 3/14/2026 around 9 pm. This failure resulted in Resident 1 having a successful elopement and had the potential to lead to endangerment, accident and injury while outside the facility's premises without supervision from staff. Resident 1 was returned to the facility on 3/15/2026 at 1:15 PM.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included but not limited to unsteadiness of feet, other schizoaffective disorders (a mental health problem where a person experiences loss of contact with reality as well as mood symptoms), and other specified…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review, the facility failed to maintain accurate documentation of wound care treatments for one (1) of two (2) sampled residents (Resident 1) on the resident's Treatment Administration Record (TAR) in accordance with the facility's policy. This deficient practice had the potential to result in miscommunication among staff and resulted in inaccurate representation of care provided to Resident 1.Findings: During a review of Resident 1's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included muscle contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) of the left and right lower leg. During a review of Resident 1's Care Plan revised on 9/11/2025, the Care Plan indicated Resident 1 had wounds on the base and shaft of the fifth (5th ) metatarsal (long bone on the outer edge of the foot that connects to the smallest toe) and on the left…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 formulate comprehensive person-centered care plans for one (1) of 3 sampled residents (Resident 1) as indicated on the facility's policy by failing to: Having care plan and document evidence to monitor the side effects and effectiveness of the use of two antibiotic medications (a drug used to treat infections caused by bacteria and other microorganisms) Document evidence of Resident 1's Right hip dislocation and care plan to implement hip precautions and monitor Resident 1's condition. These deficient practices had the potential negative effects, worsening outcomes/conditions and lead to hospitalization for Resident 1. Findings:During a review of Resident 1's admission Record, the admission record indicated Resident 1 was admitted to the facility on [DATE] and re-admitted [DATE]. Resident 1's diagnoses included right hip prosthesis sequela (refers to the long-term consequences or complications arising from a right hip replacement. These…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide the necessary wound care and treatment for one (1) of three (3) sampled residents (Resident1) accordance with facility's policy ( Wound Care) when: a. Licensed Nursing staff did not monitor Resident 1 for signs and symptoms of infection, pain and discomfort of the right hip abscess (collection of pus in any part of the body) on every shift from 6/1/2025 - 6/23/2025.b. Treatment orders were not provided on every shift from 6/1/2025 - 6/23/2025. These deficient practices had the potential to delay in healing Resident 1's right hip abscess which can lead to worsening of the wound and affect the resident's overall well-being and quality of life. Findings: During a review of Resident 1's admission Record, the admission record indicated Resident 1 was admitted to the facility on [DATE] and re-admitted [DATE]. Resident 1's diagnoses included right hip prosthesis sequela (refers to the long-term consequences or complications arising from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report allegation of sexual abuse for one of three sampled residents (Resident 2) to the California Department of Public Health (CDPH), the Ombudsman (an official appointed to investigate individuals' complaints against maladministration), and to the local law enforcement in accordance with the facility ' s policy and procedure. This deficient practice potentially delays the investigation and prevention of abuse, and put Resident 2 and other residents in the facility at risk of further abuse. Findings: During a review of Resident 2's admission Record (AR), the AR indicated the facility readmitted to the facility on [DATE] with diagnoses that including but not limited to sequelae of cerebral infarction (long-term effects of a stroke {damage to the brain from blood supply interruption}), anxiety disorders (feelings of worry , anxiety, or fear that interfere with daily living), and depressive episodes (loss of interest in activities). During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the call light system was functioning for one out of three sampled residents (Resident 1). This deficient practice at risk in delay response to resident's requests, ensure resident's safety and fulfill the needs of resident's care. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility readmitted to the facility on [DATE] with diagnoses that including but not limited to Parkinson's disease (affects movement often including tremors), chronic obstructive pulmonary disease (lung disease), and schizophrenia (disorder that affects ability to think, feel, and behave clearly). During a review of Resident 1's History & Physical (H&P), dated 4/27/24, the H&P indicated Resident 1 had fluctuating mental status/capacity (periods of capacity followed by periods of cognitive {ability to understand and process thoughts}). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 storage of food was done in a safe and sanitary conditions according to the facility's policy and procedure (P&P) for twelve (12) residents reviewed for kitchen by failing to ensure: 1. Opened container of pancake and waffle syrup and creamy Italian dressing were dated with the use by date. 2. Frozen vegetables stored in the freezer were labeled with the name of the food item and dated with the use by. This deficient practice had the potential to result in residents ingesting expired food which can result in foodborne illnesses (food poisoning) with symptoms including upset stomach, vomiting, diarrhea, and fever and had the potential for the facility to serve food items not included in the scheduled menu. Findings: During a concurrent observation and interview on 4/14/2025, at 7:37 AM, of the facility kitchen, with the Dietary Supervisor (DS), the following were observed: a. One opened container of Creamy Italian Dressing in the refrigerator with a handwritten label on the lid indicating, D…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observe infection control measures for five (5) of nine (9) sampled residents (Residents 9, 40, 42, 150 and 17) as indicated on the facility policy and procedure (P&P) when the facility failed to: 1-4. Ensure facility staff donned (put on) full personal protective equipment (PPE; clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) and/or a N95 respirator (a disposable face mask that covers the user's nose and mouth which offers protection from small solid or liquid droplets found in the air) before entering a Coronavirus (SARS-CoV-2/COVID-19; a disease caused by coronavirus characterized mainly by fever and cough and can progress to severe symptoms) positive room under contact (a type of transmission-based precaution [TBP; infection control measures used in healthcare settings to prevent the spread of pathogens] used for residents with diseases caused by microorganisms…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 dignity and respect for one of one sampled resident (Resident 36) when Certified Nursing Assistant 4 (CNA 4) took food items from Resident 36's bedside table and washed Resident 36's boots without asking permission. These deficient practices have the potential to negatively affect Resident 36's sense of self-esteem and self-worth and can lead to social isolation/ distress. Findings: During a review of Resident 36's admission Record, the admission Record indicated Resident 36 was admitted to the facility on [DATE] with diagnoses that included other sequelae of cerebral infarction (long term deficits or impairments that can result from loss of blood flow to the brain), chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), and respiratory failure. During a review of Resident 36's Minimum Data Set (MDS- a resident assessment tool), dated 2/14/2025, the MDS indicated Resident 36 was assessed having…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to have a documented evidence that restorative nursing (a program available in nursing homes that helps residents maintain any progress made during rehabilitation therapy treatments, enabling the residents to function at a high capacity) care was provided on 4/1/2025 to 4/8/2025 and 4/10/2025 to 4/13/2025 for one of two sampled residents (Resident 18) with limited range of motion (ROM- the extent of movement of a joint) and limited mobility: This deficient practice placed Resident 18 at risk for further decline in physical function and contractures (condition of shortening and hardening muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). Findings: During a review of Resident 18's admission Record, the admission Record indicated Resident 18 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included other secondary parkinsonism (movement disorders similar 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 provide appropriate care to prevent complications of a gastrostomy tube (g-tube; a surgical opening fitted with a tube device to allow feedings to be administered directly to the stomach common for people with swallowing problems) for one (1) of four (4) sampled residents (Resident 32) in accordance with the facility's policy and procedure (P&P) by not ensuring Licensed Vocational Nurse 2 (LVN 2) checked Resident 32's g-tube placement prior to administering a water flush (the process of gently pushing water through the g-tube to keep it from clogging) and medication administration. This failure had the potential to result in Resident 32 aspirating (when something enters the airway of lungs by accident) which could lead to lung problems such as pneumonia (a lung infection) and result in death. Findings: During a review of Resident 32's admission Record, the admission Record indicated the resident was initially admitted to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to post a No Smoking/Oxygen in Use sign outside of the room entrance door for one of one sampled resident (Resident 98) to indicate the presence of oxygen as indicated in the facility's policy and procedure (P&P). This deficient practice had the potential to place the residents, staff, and visitors at risk for injury in an event of a fire. Findings: During a review of Resident 98's admission Record, the admission Record indicated Resident 98 was admitted to the facility on [DATE] with diagnoses that included respiratory disorders in diseases classified elsewhere, dyspnea (shortness of breath), and atelectasis (complete or partial collapse of a lung or a section of a lung). During a review of Resident 98's Minimum Data Set (MDS- a resident assessment tool), dated 4/2/2025, the MDS indicated Resident 98 was assessed having intact cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 psychotropic medications (any drug that affects brain activities associated with mental processes and behavior) were not used unnecessarily for one of five sampled residents (Resident 35) reviewed for unnecessary medications by failing to: 1. Implement the gradual dose reduction (GDR- is the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) recommendation from the consulting pharmacist to decrease Resident 35's Lexapro (medication used to treat depression [mood disorder characterized by a persistent sad, hopeless, or empty mood that can interfere with daily life] and anxiety [a feeling of apprehension, worry, or nervousness, often related to an impending threat of danger]). 2. Monitor and document for efficacy (effectiveness), and specific target behaviors: extreme sadness causing social withdrawal a state of decreased or absent interaction…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 bowel and bladder assessment was documented accurately for one (1) of 12 sampled residents (Resident 33) as indicated in the facility policy. This failure had the potential for Resident 33 not to receive the appropriate incontinent (unable to control the blader or bowels resulting in the involuntary release of urine or feces) bowel and bladder care, which could lead to skin breakdown. Findings: During a review of Resident 33's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of metabolic encephalopathy (a brain disorder caused by problems with the body's chemistry and metabolism) and Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities). During a review of Resident 33's Minimum Data Set (MDS - a resident assessment tool), dated 2/20/2025, the MDS indicated the resident was severely impaired with cognitive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 (a visible and audible alarm activated by a call button) for one of 12 sampled residents (Resident 23) was within reach as indicated on care plan and facility's policy. This failure placed Resident 23 at risk for experiencing a delay in receiving assistance from facility staff which could lead to a fall or accident. Findings: During a review of Resident 23's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of rhabdomyolysis (a serious medical condition where muscle tissue breaks down, releasing harmful substances into the bloodstream) and lack of coordination. During a review of Resident 23's Minimum Data Set (MDS - a resident assessment tool), dated 1/24/2025, the MDS indicated the resident was severely impaired (difficulty with or unable to make decisions, learn, remember things) with cognitive (ability to think,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 alleged sexual abuse (the act of engaging in sexual activity with someone without their consent, or by using force or coercion) for one (1) of three sampled residents (Residents 1) within 2-hour timeframe to the State Survey Agency (SA, where state law provides for jurisdiction in long-term care facilities), ombudsman (OMB) (advocates for residents of nursing homes, board and care homes and assisted living facilities), and local law enforcement when OMB and local law enforcement went to the facility to investigate the allegation of sexual abuse made by Resident 1 on 3/5/2025. This deficient practice had the potential to compromise or impede the protection of Resident 1, which could affect resident's physical, emotional, and mental wellbeing. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of diabetes mellitus type 1 (DM…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that the call light (a device used by patients to call for assistance from hospital staff) was within reach (an arm's length) of one of three sampled residents (Resident 2). This deficient practice had the potential to result in delayed provision of services, delay in care and not receiving assistance with activities of daily living (ADLS, activities related to personal care. They include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating). Findings: During a review of the admission record indicated Resident 2 was initially admitted to the facility on [DATE] and re admitted on [DATE], with diagnoses that included but not limited to difficulty in walking, other lack of coordination, unspecified protein calorie malnutrition (a disorder caused by a lack of proper nutrition or an inability to absorb nutrients from food), unspecified dementia (a term used to describe a group 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 prevent a fall (unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force) for one (1) out of three (3) sampled residents (Resident 1). On 5/26/2024, Resident 1 was trying to transfer to bed, Certified Nurse Assistant (CNA) 1 was present in the room and did not assist the resident while transferring to bed. This deficient practice has resulted to Resident 1 had a fall on 5/26/2024 and sustained laceration (measurement not indicated) on her left eyebrow. Findings: A review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses of dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), history of falling, fracture of left lateral orbital wall (occurs when one or more of the bones around the eyeball break, often caused by a hard blow to the face), lack 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 readmit one of one sampled resident (Resident 1) back to the facility on 5/22/2024 after the resident was hospitalized at the General Acute Care Hospital (GACH). This deficient practice resulted in the violation of Resident 1's right to resume residency at the facility and had the potential to cause psychosocial harm. Findings: A review of Resident 1's admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included type 2 diabetes mellites (DM2 - condition that results in too much sugar circulating in the blood), hemiplegia (paralysis of one side of the body) and hemiparesis (inability to move one side of the body) affecting right dominant side, acute kidney failure (the sudden and rapid loss of kidney's ability to filter waste and balance fluid in blood), acute respiratory failure (a sudden condition in which not enough oxygen passes from the lungs into the blood), 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 report an alleged violation of abuse within two hours AND to California Department of Public Health (CDPH) for one of one resident (Resident 1) as indicated in the facility's policy and procedure (P&P). This failure resulted in the facility not reporting the occurrence of alleged abuse to all entities indicated in facility policy. Findings During a review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that include legal blindness, anxiety disorder (mental disorder involves persistent and excessive worry that can interfere with daily activities) and type 2 diabetes mellitus (DM2 - condition that results in too much sugar circulating in the blood). During a review of Resident 1's Minimum Data Sheet (MDS, a standardized assessment and screening tool) dated 5/7/2024, indicated Resident 1 has an intact ability to think, remember and reason and is supervision or touching assistance (staff provides…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prevent further allegations of abuse against the Social Services (SS) by failing to suspend SS after initial alleged violation and failing to submit the 5 day follow up investigation report to California Department of Public Health (CDPH) for one of one sampled resident (Resident 1) as indicated in facility's policy & Procedure (P&P). This deficient practice resulted in the facility's failure to provide evidence that the alleged violation of abuse was thoroughly investigated and had the potential risk of failure to protect Resident 1 from abuse. Findings: During a review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that include legal blindness, anxiety disorder (mental disorder involves persistent and excessive worry that can interfere with daily activities) and type 2 diabetes mellitus (DM2 - condition that results in too much sugar circulating in the blood). During a review of 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 transmit a Minimum Data Set (MDS, a standardized assessment and care-screening tool) Discharge Tracking Form (DTF, submitted when a resident has been discharged from the facility) to CMS (Centers for Medicare and Medicaid Services) within 31 days after a resident's DTF was completed for two of four sampled resident (Resident 17 and 37). This failure had the potential to result in an inaccurate assessment of the facility's quality indicators (standardized, evidence-based measures of health care quality that can be used with readily available in the healthcare setting) and/or care area concerns for review. Findings: A record review of Resident 17's admission Record (AR), the AR indicated Resident 17 was admitted to the facility on [DATE] with multiple diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), dementia (a group of thinking and social symptoms that interferes with daily…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 remove and discard ground beef from the refrigerator after it was past the use by date according to the facility's policy and procedure (P&P) titled, Refrigerators and Freezers. This failure had the potential to result in residents to experience food-borne illnesses (an illness that comes from eating contaminated food. The onset of symptoms may occur within minutes to weeks and often presents itself as flu-like symptoms, as the ill person may experience symptoms such as nausea, vomiting, diarrhea, or fever). Findings: During a concurrent observation, interview, and record review on 5/3/2024 at 5:57 pm with the [NAME] (CK) in the kitchen, a package of unfrozen ground beef was observed in the refrigerator. The package of ground beef was sitting in a stainless-steel pan that had a label on it indicating, ground beef for dinner 4/13/2024. The Meat Thawing Schedule, dated April 2024 was posted on the door of the refrigerator. The Meat Thawing Schedule indicated on 4/26/2024, frozen ground beef was placed in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed comply with requirements of Binding Arbitration Agreements (require that persons who signed them resolve any disputes by binding arbitration [alternative dispute resolution in which both parties agree to have their case heard by a neutral party instead of a judge and jury], rather than in court before a judge and/or jury) for three of three sampled residents (Residents 12, 19, and 200) when: 1. Facility failed to ensure Resident 12, who signed an Arbitration Agreement, dated 3/13/2024, understand what a Binding Arbitration Agreement was. 2. Facility failed to ensure Resident 19's Arbitration Agreement, dated 11/20/2020 was not signed in two locations/ options. It indicated, Resident 19 agreed to enter a Binding Arbitration Agreement and indicated the resident declined to enter a Binding Arbitration Agreement with the facility. 3. Facility failed to ensure Resident 200's (who is self-responsible) Arbitration Agreement, dated 4/30/2024, was not signed 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 staff failed to maintain an infection control measure designed to provide safe, sanitary equipment and prevent the development and transmission of disease and infection by failing to sanitize blood pressure cuff (device for measure blood pressure) between residents' use for two of six sampled residents (Residents 12 and 34). This deficient practice has the potential for communicable disease (also known as contagious disease, an infection transmissible by direct contact with an affected individual or the individual's body fluids or by indirect means like contaminated object) to spread out to others. Findings: During a review of Resident 34's admission Record indicated, Resident 34 was readmitted on [DATE], with diagnoses that included hypertensive heart disease with heart failure (heart problem caused by high blood pressure) and respiratory failure (a serious condition that makes it difficult to breathe on your own). During a review of Resident 12's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain informed consents (a process in which a health care provider educates a resident about the risks, benefits, and alternatives of a given procedure or intervention) for the use of psychotropic medications (medications that affect the mind, emotions, and behavior) for two (2) of five (5) sampled residents (Resident 44 and Resident 101) as indicated on the facility policy and procedure. 1. Facility failed to obtain an informed consent from Resident 44's Responsible Party (RP) prior to use of Seroquel (Antispychotic medication). 2. Facility failed to obtain an informed consent from Resident 101 prior to use of lorazepam (Antianxiety medication) and quetiapine (Seroquel). This failure resulted in violating resident's right to be fully informed of the risks and benefits of proposed care and treatment and not be able to make a choice on the treatment alternatives. Findings: 1. During a review of Resident 44's admission Record indicated Resident 44 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 observation, interview, and record review, the facility failed to ensure the call light (a device used by a resident to signal their need for assistance from staff) was within sight and within reach for four (4) of 14 sampled residents (Residents 16, 35, 41, and 100) while in bed. This failure had the potential for Residents 16, 35, 41, and 100 to not be able to call for assistance if the residents desired to. Findings: 1. During a review of Resident 16's admission Record, the admission Record indicated Resident 16 was readmitted to the facility on [DATE] with diagnoses which included dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and Parkinsonism (brain conditions that cause slowed movements, rigidity/stiffness, and tremors). During a review of Resident 16's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 3/25/2024, the MDS indicated Resident 16's cognitive skills (functions that the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the responsible party (RP, responsible for guiding, informing, assisting, and advocating for residents in the healthcare system) for one (1) of two (2) sampled residents (Resident 38), who did not have the capacity to understand, received information regarding resident's right to formulate an advance directive (a legal document that states resident's wishes about receiving medical care if that resident is no longer able to make medical decisions because of a serious illness or injury). This failure had the potential to violate Resident 38's and Resident 38's RP's right to formulate an advance directive. Findings: During a review of Resident 38's admission Record, the admission Record indicated Resident 38 was admitted to the facility on [DATE] with diagnosis which included dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). During a review of Resident 38's Advance…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 (MD) of a change of condition for one of 14 sampled residents (Resident 22) after a fall on 4/24/2024. This deficient practice had the potential to not provide the necessary care and services needed by Resident 22, which can affect resident's overall wellbeing. Findings: During a review of Resident 22's admission Record, the admission Record indicated Resident 22 was readmitted to the facility on [DATE] with diagnoses which included head injuries, end stage renal disease (ESRD, when the kidneys can no longer clean the blood), and dependence on renal dialysis (a procedure where a machine cleans the blood because the kidneys can no longer clean the blood). The admission Record indicated Resident 22 had a history of falling. During a review of Resident 22's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated 1/24/2024, the H&P indicated Resident 22 was competent to understand 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 observation, interview and record review, the facility failed to develop a baseline care plan (initial goals based on admission orders which provides instructions for immediate care of the resident) for one (1) of 14 sampled residents (Resident 101) within 48 hours of Resident 101's admission to the facility. This failure had the potential for Resident 1 to not receive adequate and appropriate care. Findings: During a review of Resident 101's admission Record, the admission Record indicated Resident 101 was admitted to the facility on [DATE] with diagnoses which included anxiety disorder, schizophrenia (a serious mental illness that interferes with a person's ability to think clearly, manage emotions, make decisions, and relate to others), and malnutrition (occurs when the body does not get enough nutrients). During a review of Resident 101's History and Physical (H&P, physician's clinical evaluation and examination of the resident), the H&P indicated Resident 101 was able to make decisions 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 develop and implement a care plan to address resident's behavior of getting up out of the wheelchair unassisted for one of 14 sampled residents (Resident 22) as indicated on the facility policy and procedure. This deficient practice had the potential for Resident 22 to fall and result in injury. Findings: During a review of Resident 22's admission Record, the admission Record indicated Resident 22 was readmitted to the facility on [DATE] with diagnoses which included head injuries, end stage renal disease (ESRD, when the kidneys can no longer clean the blood), and dependence on renal dialysis (a procedure where a machine cleans the blood because the kidneys can no longer clean the blood). The admission Record indicated Resident 22 had a history of falling. During a review of Resident 22's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated 1/24/2024, the H&P indicated Resident 22 was competent 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 a nephrostomy (a surgical opening from the outside of the body to the renal pelvis [part of the kidney that collects urine] connected by a urinary tube/catheter [a plastic like tube placed in the body to drain and collect urine from the bladder {sac like that collects urine}]) bag was positioned below the bladder, the nephrostomy bag was placed on bed next to the resident, for one of two sampled residents (Resident 26), This deficient practice had the potential for urinary tract infection if the urine in the tubing or drainage bag back flow into kidney. Findings: During a review of Resident 26's admission Record indicated Resident 26 was readmitted to the facility on [DATE], with diagnoses that included acute kidney failure (kidney suddenly become unable to filter waste products from blood) and infection (involves tissue invasion by microorganisms) and inflammatory (the body's response to a potentially damaging stimulus) reaction…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 act upon the pharmacist's recommendations for A1C blood test (a blood test that provides information about levels of blood sugar over the past 3 months, used to diagnose type 2 diabetes [a disease that occurs when blood sugar is too high] and prediabetes) from medication regimen review (MRR, a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences associated with medication by pharmacist) for one (1) of 14 sampled residents (Resident 44). This failure had the potential to result in resident had uncontrolled blood sugar level that cause affect their health conditions. Findings: During a review of Resident 44's admission Record indicated Resident 44 was admitted on [DATE], with diagnoses that included type 2 diabetes and psychosis (a severe mental condition in which thought, and emotions affected that contact is lost with external reality). During a review of 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 observation, interview, and record review, the facility failed to ensure safe keep of medications when medications were left unattended during a medication administration observation for one of four sampled residents (Resident 34). This failure had the potential to result in loss of medications and/or other residents accessing the medications which could result in adverse effect (a harmful and undesired effect resulting from a medication or intervention) in the event that the medications were ingested. Findings: During a review of Resident 34's admission Record, the admission Record indicated Resident 34 was readmitted on [DATE], with diagnoses that included hypertensive heart disease with heart failure (heart problem caused by high blood pressure) and respiratory failure (a serious condition that makes it difficult to breathe on your own). During a medication administration observation at the hallway on 5/4/2024 at 8:17 am, Licensed Vocational Nurse 2 (LVN2) took out Resident 34's six medications 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 implement its Policy and Procedure (P&P) for Influenza (a highly contagious viral illness that infect the nose, throat, and lungs) and Pneumococcal (pneumonia, infection of one or both lungs) Vaccination (treatment to a particular infectious disease) for one (1) of five (5) sampled residents (Resident 12) by failing to ensure: a. Resident 12's influenza vaccine and pneumococcal vaccine administration was recorded in Resident 12's Immunization Record. b. Resident 12 was monitored for side effects after Resident 12 received an influenza and a pneumococcal vaccine. These failures had the potential for Resident 12 to not receive care and treatment for side effects from the influenza and pneumococcal vaccines. Findings: During a review of Resident 12's admission Record, the admission Record indicated Resident 12 was admitted to the facility on [DATE] with diagnoses which included colon (main part of the large intestines, which absorb water and electrolytes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 develop a comprehensive resident - centered care plan for one (1) of three (3) sampled residents (Resident 1) per facility ' s policy. This deficient practice had the potential for Resident 1 to not receive specific interventions to prevent decline in the resident ' s functional ability, which could result in injury and harm. Findings: A review of Resident 1 ' s admission Record indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 1's diagnoses included cerebral infarction (refers to damage to tissues in the brain due to a loss of oxygen to the area), Parkinson ' s disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), and osteoporosis (disease which makes bones weak and fragile). A review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 1/30/2024,…

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

Based on interview, and record review, the facility failed to ensure the Licensed Vocational Nurses (LVNs) annual competency skills were checked and completed based on the facility's policy and procedure. This failure had the potential to not meet the specific competency requirements of the Licensed Nurses competency skills annually, which could affect the residents during provision of nursing services. Findings During an interview with the Director of Staff Development (DSD) 1 on 12/27/2023 at 3:32 PM, DSD 1 stated she does not have a licensed competency skills log for the licensed nurses. During an interview with the Director of Nursing (DON) on 12/27/2023 at 3:41 PM, the DON stated, Annual competency is conducted on the Licensed Nurse's anniversary date, which is every year on the LVN's employment date. DSD 1 is in charge of the annual competency of the licensed nurses and the nursing assistants in the facility because that is part of her job as the staff developer. The DON did not answer and stayed silent when asked how does DSD 1 track down the annual skills competency of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide oxygen therapy (treatment that provides supplemental, or extra oxygen) and necessary respiratory care services for one (1) of five (5) sampled residents (Resident 1) in accordance with the facility's policy and procedure when: 1. Resident 1's oxygen humidifier bottle was empty and did not have sterile water (water that is free of any microbes [tiny living things that are found all around us and are too small to be seen by a naked eye], used to prevent growth of organisms and bacteria in the water). This deficient practice had the potential to create discomfort and dryness to the nasal passages which can lead to serious complications. 2. Resident 1's nasal cannula (a device that delivers extra oxygen through a tube and into your nose) was properly placed on her nostrils (two openings in the nose through which air moves when you breathe). This deficient practice placed 1 at risk for shortness of breath and/or hypoxia (low levels of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure certified nurse assistant (CNA) 1 provided care and services for one of 4 sampled residents (Resident 1) with activities of daily living for toilet use. This deficient practice resulted in Resident 1 falling and sustaining head abrasion (scratch). Resident was transferred to a General Acute Care Hospital (GACH) for further eval due to unwitnessed fall. Findings: A review of the Face Sheet (admission Record) indicated Resident 1 was originally admitted on [DATE] and was readmitted in 7/30/2023 with diagnoses including but not limited to difficulty in walking, dementia (brain disease causing memory problems), diabetes mellitus (high blood sugar), and cerebral infarction (lack of blood flow resulted in severe damage to some of the brain tissue). A review of the Minimum Data Set (MDS - a comprehensive assessment and screening tool), dated 4/21/2023, indicated Resident 1's cognitive skill (mental action or process of acquiring knowledge 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 one of four sample residents (Resident 1) who is at risk for falls was assisted by staff during toilet use as indicated in the resident's functional assessment. This deficient practice resulted in Resident 1 falling and sustaining a head abrasion (scratch) on the right side of his head. Resident was transferred to a General Acute Care Hospital (GACH) for further evaluation due to unwitnessed fall. Findings: A review of the Face Sheet (admission Record) indicated Resident 1 was originally admitted on [DATE] and was readmitted in 7/30/2023 with diagnoses including but not limited to difficulty in walking, dementia (brain disease causing memory problems), diabetes mellitus (high blood sugar), and cerebral infarction (lack of blood flow resulted in severe damage to some of the brain tissue). A review of the Minimum Data Set (MDS - a comprehensive assessment and screening tool), dated 4/21/2023, indicated Resident 1's cognitive skill (mental action 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.