Chino Valley Health Care Cente

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report for one of five sampled residents (Resident 3) to the California Department of Public Health (the Department), to the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), and to the local law enforcement a resident-to-resident altercation within two hours in accordance with the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigation, dated September 2022.This failure resulted in the delay of notification to the Department and had the potential for Resident 3 to be subjected to abuse while at the facility.A. During a review of Resident 3's Face Sheet (FS-document that contains a patient's personal and contact information, diagnoses and brief medical history, allergies, and name and contact information of patient's physicians), the FS indicated the facility readmitted Resident 3 on 3/19/2026 with diagnoses including…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 (1) of three (3) sampled residents (Resident 11) who was re-admitted to the facility after a surgical procedure had a skin assessment.This failure had the potential for Resident 11 receiving delayed care and treatment for Resident 11's surgical wounds which could lead to infection.During a review of Resident 11's Face Sheet (FS, document that contains a patient's personal and contact information, diagnoses, and medical history), the FS indicated Resident 11 was re-admitted to the facility on [DATE] with diagnoses that included lack of coordination and displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing (patient had surgery on the left thigh bone and is now in the healing phase).During a review of Resident 11's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated 10/5/2025, the H&P indicated Resident 1 did not have 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 implement its abuse prevention policy by failing to report one allegation of injury of unknown origin to the state agency (Department of Public Health) and law enforcement within the required reporting time frames for one of five sampled residents (Resident 2).This deficient practice delayed the investigation of abuse and placed Resident 2, and other residents at risk for abuse and feelings of intimidation.Findings: During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy (a change (confusion, memory loss or loss of consciousness) in how your brain works due to an underlying condition), unspecified dementia with anxiety (significant cognitive decline and excessive worry or restlessness), and long-term use of anticoagulants (medications that prevent or reduce blood clotting). During a review of Resident 2's History and…

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

Based on observation, interview and record review, the facility staff member failed to notify the responsible party when 1 of 3 sample residents (Resident 1) moved to another room. This failure resulted in lack of timely communication with Resident 1's responsible party regarding changes in Resident 1's Room/environment.During a review of Resident 1's admission Record (AR-Face Sheet), the AR indicated the facility admitted Resident 1 on 2/5/2026, with diagnoses including dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury), and Alzheimer's disease (progressive mental deterioration).During a review of Resident 1's History and Physical (H&P), dated 2/7/2026 the H&P indicated, Resident 1 does not have the mental capacity to make medical decisions.During a review of Resident 1's Minimum Data Set (MDS-a federally mandated resident assessment tool), dated 2/11/2026, the MDS indicated the cognitive (the ability to think and process information) skills for daily decisions making was moderately impaired, and required partial/moderate…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 adequate supervision for 1 of 3 sampled residents (Resident 1) who required supervision during showers.This failure resulted in Resident 1 being found in the shower area without staff supervision, placing the resident at risk for injury.Findings:During a review of Resident 1's admission Record (AR-Face Sheet), the AR indicated the facility admitted Resident 1 on 2/5/2026, with diagnoses including dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury), and Alzheimer's disease (progressive mental deterioration).During a review of Resident 1's History and Physical (H&P), dated 2/7/2026 indicated, the H&P Resident 1 does not have the mental capacity to make medical decisions.During a review of Resident 1's Minimum Data Set (MDS-a federally mandated resident assessment tool), dated 2/11/2026, the MDS indicated Resident 1's cognitive (the ability to think and process information) skills for daily decisions making was moderately impaired, and required partial/moderate…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care plan (individualized document developed to manage a patient's physical, mental, emotional, and social health needs) with interventions (action taken to improve a situation) for three of eight sampled residents (Residents 3, 6 and 7).Findings:1. During a review of Resident 3's admission Record (AR), the AR indicated Resident 3 was admitted to the facility on [DATE] and was readmitted to the facility on [DATE] with diagnoses that included encephalopathy (disturbance of the brain's functioning that leads to problems like confusion and memory loss) and respiratory failure (serious condition that makes it difficult to breathe, lungs cannot get enough oxygen into the blood).During a review of Resident 3's History and Physical Examination (H&P, physician's clinical evaluation and examination of the resident), dated 3/28/2026, the H&P indicated Resident 3 did not have the capacity to understand and make…

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

Based on interview and record review the facility failed to ensure an adequate amount of Certified Nursing Assistants (CNAs) worked in the South Dementia unit (unit designed to meet the specific needs of residents with dementia [a progressive state of decline in mental abilities]) on the NOC shift (overnight shift from 11 pm to 7 am) on 3/8/2026, 3/11/2026 and 3/21/2026, in accordance with the facility's Facility Assessment Tool (FAT - facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies), dated 3/19/2026. This failure had the potential to result in residents receiving inadequate care and supervision which can lead to falls, elopement, and delayed recognition of residents' significant changes in condition.Findings:During a concurrent interview and record review on 4/2/2026 at 11:30 am with Director of Staff Development (DSD), the FAT, the Nursing Staffing Assignment and Sign-in Sheet from 3/1/2026 to 3/31/2026, and CNA Timecards were reviewed. The FAT, dated 3/19/2026, indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to complete an SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) Communication Form for two of eight sampled residents (Resident 3 and Resident 7) in accordance with the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status when:1. There was no SBAR found in Resident 3's medical record regarding Resident 3's skin rash (abnormal changes in skin color or texture and are typically associated with irritation or swelling) on both hands. 2. There was no SBAR found in Resident 7's medical record regarding Resident 7's generalized body rash.These deficient practices placed Resident 3 and Resident 7 at risk of not receiving appropriate care.Findings: 1. During a review of Resident 3's admission Record (AR), the AR indicated Resident 3 was admitted to the facility on [DATE] and was readmitted to the facility on [DATE] with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to provide an accessible call light system as indicated in the facility's policy and procedure titled, Call System, Residents, by failing to ensure the call light pull cords were within reach from the floor for ten of 10 sampled residents (Residents 4, 15, 16, 20, 21, 22, 23, 24, 25, and 26) when using Bathroom [ROOM NUMBER] and Bathroom [ROOM NUMBER].This deficient practice had the potential to delay the provision of care for Residents 4, 15, 16, 20, 21, 22, 23, 24, 25, and 26 and negatively affect the residents' well-being when the residents were unable to call staff for assistance.Findings:1. During a review of Resident 4's admission Record (AR), the AR indicated, the facility initially admitted Resident 4 to the facility on [DATE], and readmitted Resident 4 on 10/8/25, with diagnoses that included metabolic encephalopathy (a group of conditions that causes brain dysfunction which alters brain function or structure), and schizophrenia (a chronic mental…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an allegation of abuse for one of four sampled residents (Resident 15) to the California Department of Public Health (the Department), the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), and to the local law enforcement within two hours, in accordance with the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, dated 9/2022.This failure resulted in the delay of notification to the Department and had the potential to result in Resident 15 to be subjected to abuse while at the facility.Findings:a. During a review of Resident 15's admission Record (AR), the AR indicated Resident 15 was originally admitted to the facility on [DATE], and readmitted the resident on 9/24/2025 with diagnoses that included anxiety disorder (a mental health condition causing excessive, persistent fear and worry disproportionate 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 and interview, the facility failed to maintain a safe and sanitary shower for 1 out of 1 shower room in the facility where a black substance was observed on the tile under the shower handle.This deficient practice had the potential for all residents who used the shower to be placed at risk for respiratory health hazards.Findings:During an observation on 1/22/26 at 2:57 p.m. in Bathroom [ROOM NUMBER] with CNA 27, Bathroom [ROOM NUMBER] was observed to be large enough to accommodate a shower across from the toilet area. A black substance on the tile (2 tiles in length; or 8 inches) was observed below the shower handle and above the grab bar.During a concurrent observation and interview on 1/22/26 at 3:21 p.m. in Bathroom [ROOM NUMBER] with the Maintenance Assistant (MA), MA stated the black substance on the shower tiles was mold and should be cleaned right away.During a concurrent observation and interview on 1/22/26 at 3:32 p.m. in Bathrooms #3 with the Housekeeping Supervisor (HKS), HKS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, the facility failed to maintain safe food handling practices according to the facility's policies and procedures (P&P) titled, Daily Food Temperature Control, and Refrigerator/Freezer Storage, by failing to:1. Ensure the temperatures of freezer 1, freezer 2, refrigerator (fridge) 1, and fridge 2 were checked and logged from 9/3/2025 to 9/18/2025.2. Ensure the temperatures of freezer 2 that stored ice cream, remained below zero (0) degrees Fahrenheit (F- unit of temperature measurement) and fridge 1 that stored milk and dairy products, remained below 40 degrees F.3. Ensure the temperature of the milk in fridge 1 remained below 40 degrees F.4. Ensure the temperatures of food served during the tray line (the plating of hot and cold food being served to residents each meal) were checked logged before serving breakfast and lunch 9/3/2025 to 9/17/2025, dinner 9/2/2025, 9/8/2025, 9/9/2025, 9/14/2025, and 9/15/2025, and breakfast on 9/18/2025.5. Ensure the gravy was kept on the steam table and that the temperatures of gravy, milk and fish were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 privacy during provision of perineal care (cleaning and maintaining the area between the anus and the genitals) and changing of incontinence briefs (disposable diaper) for two of two sampled residents (Resident 1 and Resident 3).This failure had the potential to result in Resident 1 and Resident 3 feeling embarrassed and having loss of self-esteem.a. During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 8/12/2025 with diagnoses which included hypertension (high blood pressure), and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 8/18/2025, the MDS indicated Resident 1 had moderately impaired cognitive skills (ability to make daily decisions), required partial/moderate assistance (helper does less than half the effort) with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure infection control practices were implemented when one of one Certified Nurse Assistant (CNA 1) did not wash or sanitize hands after exiting Resident 1's shower room and before touching Resident 2.This deficient practice had the potential to result in cross contamination (transfer of germs and harmful substance) and spread of infection.Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility readmitted the resident to the facility on 7/31/25 with diagnoses that included type 2 diabetes mellitus (elevated blood sugar level) and acute kidney failure (kidneys can't filter waste).During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 7/28/25, the MDS indicated Resident 1 had moderately impaired cognitive skills (ability to understand and process thoughts) for daily decision making.During a review of Resident 1's History & Physical (H&P) dated 8/1/25, the H&P indicated…

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

Based on interview and record review, the facility failed to identify a skin rash (an area of irritated or swollen skin that can be red, itchy, painful, or bumpy) for one of one sampled resident (Resident 1) when Licensed Vocational Nurse (LVN) 1 discharged Resident 1 without doing a skin check (a visual examination of the skin surface) on 5/29/2025.This failure resulted in delayed treatment for Resident 1's skin rash and had the potential to result in physical decline to Resident 1.Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility originally admitted Resident 1 on 11/21/2023 and readmitted the resident 1/12/2024 with diagnoses including type 2 diabetes mellitus (a chronic [persistent or long-lasting] disease characterized by high blood sugar levels due to insufficient insulin [a hormone which regulates the amount of sugar in the blood] production) and major depressive disorder (mental health condition where a person experiences a persistent low mood, loss of interest in activities and other symptoms that significantly impact daily life).…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 1) who had an order of X-ray (an imaging test to create detailed pictures of the organs) of the left hand was implemented in a timely manner, as ordered. This failure had the potential for Resident 1 not to receive necessary care and services to immediately meet the resident's medical needs. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 8/9/2023 and readmitted on [DATE] with diagnoses including dementia (a group of thinking and social symptoms that interfere with daily functioning), history of falling, and age-related osteoporosis (a medical condition in which the bones become brittle and fragile) During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 4/30/2025, the MDS indicated Resident 1 had severely impaired cognitive skills (ability to make daily decisions). The MDS indicated Resident 1 required…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 privacy during assistance with personal care and during treatment procedures for two of two sampled residents (Resident 45 and Resident 202). This deficient practice had the potential to affect Resident 45 and Resident 202's feelings of self-worth and self-esteem. Findings: a. During a review of Resident 45's admission Record (AR), the AR indicated the facility admitted Resident 45 on 12/28/2017, with diagnoses that included Alzheimer's disease (irreversible, progressive brain disorder that slowly destroys memory and thinking skills, and eventually the ability to carry out the simplest tasks) and dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning). During a review of Resident 45's Minimum Data Set (MDS - a resident assessment tool) dated 1/27/2025, the MDS indicated Resident 45 rarely/never understood verbal content and rarely/never able to express ideas and wants. The MDS indicated Resident 45 was dependent on staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility staff failed to ensure Certified Nurse Assistants (CNAs) 8 and 9 know how to recognize verbal abuse and implement the facility's policy on abuse for two of two residents (Residents 23 and 47) on 4/29/2025. These deficient practices had the potential to expose other residents in the facility to abuse and cause distress, fear and nervousness. Findings: a. During a review of Resident 23's admission Record (AR), the AR indicated Resident 23 was admitted on [DATE], and re-admitted on [DATE], with diagnoses including impulse disorder (having a hard time resisting urges or impulses, often leading to unwanted behaviors), dementia (a progressive state of decline in mental abilities), and mood disorder (a mental health condition that causes significant and persistent changes in a person's emotional state, energy levels, and behavior). During a review of Resident 23's Minimum Data Set (MDS - a resident assessment tool), dated 3/21/2025, the MDS indicated…

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

Based on observation, interview, and record review, the facility failed to ensure food items in one of one kitchen were stored and distributed in a sanitary manner by failing to: a. Ensure expired dry food items were not kept in storage in one of one kitchen (Kitchen 1). b. Ensure proper ice handling practices by one of one kitchen staff (Dietary Aide 1) during lunch tray line. These deficient practices had the potential to expose 97 of 97 residents to food borne illness (any illness resulting from eating/drinking contaminated foods) and could negatively affect the health of the residents at the facility. Findings: a. During an observation on 4/28/2025 at 8:55 AM with the Dietary Manager (DM), in the dry storage area of Kitchen 1, there was one (1) pack of hamburger bun with a used by date of 4/20/2025 and 1 can of pork and beans with a use by date of 5/2024. During an interview on 4/28/2025 at 9:10 AM with the DM, the DM stated the expired hamburger bun and pork and beans would be thrown away. The DM stated the kitchen staff follow the first in, first out (valuation method where…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 gnats (a group of tiny, winged flies) were not found inside the kitchen area. This deficient practice had the potential for gnats to multiply and fly to other areas of the facility or contaminate food. Findings: During an observation on 4/28/2025 at 8:25 AM, there were 4 tiny black colored flying insects below the sink area. The [NAME] stated the flying insects were gnats. During an interview on 5/1/2025 at 5:11 PM with the Dietary Manager (DM), the DM stated food particles could attract gnats, so the staff cleaned the kitchen thoroughly after the gnats were found. The DM stated the facility needed to ensure there were no gnats present inside the kitchen because the flying insects could go to the food and contaminate the food which could affect food safety. During a review of the facility's policy and procedure (P&P) titled, Pest Control Policy, the P&P indicated the facility shall maintain an on-going pest control program to ensure that the building is kept free of insects and rodents.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 47) was free from verbal abuse as indicated by the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program. This deficient practice resulted in verbal abuse to Resident 47 and had the potential to lead to psychosocial harm to Resident 47. Cross Reference F609 Findings: During a review of Resident 23's admission Record (AR), the AR indicated the facility admitted Resident 23 on 8/26/2020, and re-admitted the resident on 9/21/2024, with diagnoses including impulse disorder (a group of behavioral conditions that make it difficult to control your actions or reactions), dementia (a progressive state of decline in mental abilities), and unspecified mood disorder (a mental health condition that causes significant and persistent changes in a person's emotional state, energy levels, and behavior). During a review of Resident 23's Minimum Data…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to report verbal abuse within two hours that involved one of one sampled resident (Resident 47) as indicated in the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating. This deficient practice prevented timely investigation and implementation of appropriate measures, which could potentially allowed continued abuse to Resident 47. Cross Reference F600 Findings: During a review of Resident 23's admission Record (AR), the AR indicated the facility admitted Resident 23 on 8/26/2020, and re-admitted the resident on 9/21/2024, with diagnoses including impulse disorder (a group of behavioral conditions that make it difficult to control your actions or reactions), dementia (a progressive state of decline in mental abilities), and unspecified mood disorder (a mental health condition that causes significant and persistent changes in a person's emotional state, energy levels, 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 enter a diagnosis of schizophrenia (a serious mental health condition that affects how people think, feel, and behave, characterized by prominent delusions [a belief or altered reality that is persistently held despite evidence or agreement to the contrary], and hallucinations [false perception of objects or events involving the senses]) in the the Minimum Data Set (MDS - a standardized assessment and screening tool) for one of one sampled residents (Resident 15). This deficient practice resulted in Resident 15's MDS not accurately reflecting Resident 15's clinical status, and had the potential to impact care planning, quality measures, and resource allocation for Resident 15. Findings: During a review of Resident 15's admission Record (AR), the AR indicated the facility admitted Resident 15 on 12/26/2023, and re-admitted the resident on 6/1/2024, with diagnoses including urinary tract infection (UTI-an infection in the bladder/urinary tract),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 implement the plan of care to prevent aspiration (when something swallowed enters the airway or lungs) and/or choking (blockage of the upper airway by food or other objects) for one of one sampled resident (Resident 32) who was assessed as being at risk for aspiration and choking. This deficient practice had the potential to result in aspiration and/or choking for Resident 32. Findings: During a review of Resident 32's admission Record (AR), the AR indicated the facility admitted Resident 32 on 1/22/2016, with diagnoses that included mood affective disorder (mental health condition that affects a person's emotional state), dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning) and dysphagia (difficulty swallowing). During a review of Resident 32's Change of Condition (COC) dated 4/5/2025, timed at 12:30 PM, the COC indicated Resident 32 was noted with delayed swallowing with episodes of coughing on liquids. The COC indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 24) who spoke primarily Mandarin had a communication board at bedside. This failure had the potential to result in Resident 24 having unmet needs and emotional distress. Findings: During a review of Resident 24's admission Record (AR), the AR indicated Resident 24 was admitted on [DATE] with multiple diagnoses including osteoporosis (condition that weakens bones, making them more prone to fractures) and chronic pulmonary edema (condition where fluid accumulates in the lungs over an extended period.) The AR further indicated Resident 24's primary language was Chinese (Mandarin). During a review of Resident 24's History and Physical (H&P), dated 2/4/2025, the H&P indicated Resident 24 had the capacity to understand and make decisions. During a review of Resident 24's Minimum Data Set (MDS - a resident assessment tool) dated 2/5/2025, the MDS indicated Resident 24 required partial or moderate…

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

Based on observation, interview, and record review the facility failed to maintain its infection prevention and control program, for one of two sampled residents (Resident 2), as indicated by the facility's Policy and Procedure (P&P) titled, Enhanced Barrier Precautions The facility failed to wear appropriate personal protective equipment (PPE- clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) while providing care and having direct physical contact with Resident 2 who was under Enhanced Barrier Precautions (EBP, an approach that entails the use of PPE to reduce transmission of multidrug-resistant organism [MDRO, bacteria that are resistant to three or more classes of antimicrobial drugs]). This deficient practice had the potential to result in the transmission of infectious microorganisms and increase the risk of infection for Resident 2 and other residents residing at the facility. Findings: During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 11/28/2003, 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 report an allegation of abuse for one of three sampled residents (Resident 1) to the California Department of Public Health (the Department), the Ombudsman (an official appointed to investigate individuals' complaints against maladministration), and to the local law enforcement, within two hours, in accordance with the facility's policy and procedure (P&P), titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised March 2023. This failure resulted in a delay in notification to the Department and had the potential to result in Resident 1 to be subjected to abuse while at the facility. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 2/14/2022 and readmitted Resident 1 on 3/29/2025 with 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 functioning), and unsteadiness of feet.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure two of 13 sampled staff understood the facility's Policies and Procedures (P&P) regarding abuse reporting by failing to: 1. Ensure Certified Nursing Assistant (CNA) 1 knew who the facility's Abuse Coordinator (a designated staff member for overseeing and coordinating the facility's efforts to prevent resident abuse) was. 2. Ensure Registered Nurse (RN) 1 knew which agencies needed to be notified about allegations of resident abuse. RN 1 did not know that all allegations of abuse must be reported to the California Department of Public Health (the Department), the Ombudsman (an official appointed to investigate individuals' complaints against maladministration), and to the local law enforcement within two hours. This failure had the potential to result in residents (in general) to be subject to abuse while residing at the facility. (Cross reference F609) Findings: During a telephone interview on 4/8/2025 at 1:38 p.m. with CNA 1, CNA 1 stated CNA 1 did not remember if CNA 1 received training from the facility regarding…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 its policy and procedure (P&P) titled, License, Certification, and Registration of Personnel, and job description (JD) titled, Director of Staffing Development (DSD- a licensed Registered Nurse [RN] or Licensed Vocational Nurse [LVN- a nurse who provides direct nursing care for people who are sick, injured, convalescent, or disabled] who is approved by the Department), for one of 15 sampled staff (previous DSD/office assistant [OA]) by failing to: Ensure that the OA did not work without a license to practice nursing from [DATE] to [DATE] while providing care to nine of nine sampled residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, and 9) and working under the title DSD. As a result of this failure, on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] the OA continued to work without a license while in a nursing role as the DSD, and administered medications and provided…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two of two sampled residents (Residents 33 and Resident 57) and/or their representatives were provided information regarding the right to formulate an advance directive (AD, legal documents that provided instructions for medical care and only went into effect if a person cannot communicate his/her own wishes). This failure had the potential to result in Resident 33 and Resident 57 and/or their representative to receive unwanted care and treatment and/or unnecessary life-sustaining treatment. Findings: a. During a review of Resident 33's admission Record (AR), the AR indicated the facility admitted Resident 33 to the facility on 7/31/2019, and re-admitted Resident 33 on 8/12/2022, with diagnosis that included dysphagia (difficulty swallowing), abnormal posture, and dementia (a decline in mental ability severe enough to interfere with daily life). The AR indicated the facility listed Family Member (FM) 1 as Resident 33's emergency contact. A…

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

Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, a standardized assessment and care-screening tool) was accurate for two of three sampled residents (Residents 7 and 8) a. Resident 7's MDS did not indicate Resident 7 had the active diagnosis of schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). b. Resident 8's MDS did not indicate Resident 8 had active diagnoses of Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) and bipolar disorder (a mental illness that causes unusual shifts in a person's mood). These failures had the potential for Residents 7 and 8 not to receive appropriate treatment and/or services. Findings: a. During a review of Resident 7's admission Record (AR), the AR indicated Resident 7 was admitted to facility on 2/11/20 with multiple diagnoses including schizophrenia and dementia (a group of thinking and social symptoms that interferes with daily functioning). During…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 monitor for side effects of psychotropic medications (medications that affects brain activities associated with mental processes and behavior) for one of five sampled residents (Resident 64) according to the facility's policy and procedure (P&P) titled, Psychotropic Medication Use, dated July 2022. This failure had the potential for Resident 64 to experience a decline in health and psychosocial well-being. Findings: During a review of Resident 64's admission Record (AR), the AR indicated Resident 64 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including type 2 diabetes mellitus (a chronic [long standing] condition that affects the way the body processes blood sugar), hypertension (high blood pressure), and schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). During a review of Resident 64's Minimum Data Set (MDS, a standardized assessment and care…

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

Based on observation, interview, and record review the facility failed to follow safe and proper food storage practices, in one of one kitchen (Kitchen 1), in accordance with professional standards for food service safety and the facility's policy and procedure (P&P) by failing to label/date food items in the kitchen. This deficient practice could result in serious complications from food borne illness (illness caused by the ingestion of contaminated food or beverage) and/or affect the quality and palatability of food to the residents. Findings: During a concurrent observation and interview on 4/29/24, at 8:34 a.m. with the Dietary Manager (DM) during the initial tour of Kitchen 1, the following were observed: 1. one undated/unlabeled 16 oz (ounces, a unit of weight) can of Sprease brand of all-purpose oil-based spray with no cap on and located on the counter by the stove. 2. 5 unlabeled/unmarked sealed plain plastic packages of multiple frozen waffles were inside the stand alone freezer. The DM stated, the opened oil spray can should have a cover on and should have been labeled 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.

Based on observation, interview, and record review the facility failed to implement the facility's policy and procedures (P&P), for food items in one of one refrigerator (Refrigerator 1), that indicated labeling food brought into the facility by family and visitors for residents, with the resident's name, the item, and the use by date when, 1. Staff did not know when to discard food brought in by family and other visitors. 2. Staff did not know who was responsible for checking Refrigerator 1 located in the South Station and determine when foods were to be discarded. These failures had the potential for residents to eat spoiled foods and develop foodborne illness. Findings: During a concurrent observation and interview on 5/1/2024 at 1:10 pm with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated, When family brings food in, we let them know we can only keep food for 24 hours. LVN 2 stated the only refrigerator used to store residents' food was in the South Station utility room. Refrigerator 1 was observed in the South Station utility room with LVN 2. There was a sealed jar of instant…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 59) was treated with dignity by failing to provide privacy while accessing Resident 59's gastrostomy tube (G-tube, a tube inserted through the belly to bring nutrition and/or medications directly to the stomach) during medication administration. This deficient practice resulted in Resident 59's legs and diaper (adult brief) getting exposed and could have resulted in Resident 59 to feel humiliated, embarrassed, and ashamed. Findings: During a review of Resident 59's admission Record (AR), the AR indicated, Resident 59 was originally admitted to the facility on [DATE] and last readmitted on [DATE] with multiple diagnoses including encounter for attention to gastrostomy (a surgical procedure used to insert a G-tube), cachexia (a general state of ill health involving great weight loss and muscle loss) and unspecified dementia (a general term for the impaired ability to remember, think, or make…

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

Based on interview and record review, the facility failed to revise the care plans for one of one sampled resident (Resident 19). The facility failed to revise Resident 19's care plans for falls regarding the use of bilateral (left and right) floor mats. This deficient practice had the potential for the Resident 19 to not receive proper and consistent care. Findings: During a review of Resident 19's admission Record (AR), the AR indicated, the facility admitted Resident 19 to the facility on 4/7/2023, and re-admitted Resident 19 on 10/4/2023, with diagnoses that included blindness, lack of coordination (not able to move different parts of the body together well or easily), unsteadiness (liable to fall, not steady in position) on feet, and dementia (a group of symptoms caused by disorders that affect the brain). During a review of Resident 19's Care Plan (CP) titled, Falling Star Program, revised on 11/14/2023, the CP indicated, Resident 19 was at risk for falls. The CP interventions included floor mats as indicated. During a review of Resident 19's Interdisciplinary Team (IDT, a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure 1 of 3 sampled discharged (when a resident no longer needs to receive services and is sent home or moved to another facility or location) residents (Resident 102) and Resident 102's family were involved in developing Resident 102's post-discharge plan prior to Resident 102's discharge on [DATE]. This failure had the potential for Resident 102 and Resident 102's family to not have the chance to ask questions regarding Resident 102's placement and post-discharge care which could result in a difficult transition to the post-discharge setting. Findings: During a review of Resident 102's admission Record (AR), the AR indicated Resident 102 was admitted to the facility on [DATE] with diagnoses that included schizophrenia (a serious mental illness that interferes with a person's ability to think clearly, manage emotions, make decisions, and relate to others). During a review of Resident 102's Minimum Data Set (MDS, a standardized assessment and care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff (Registered Nurse 2, [RN 2]) had specific competencies (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully) to communicate with Resident 33, who spoke and communicated in Arabic This deficient practice resulted in RN 2 could not understand Resident 33's needs and had the potential to result in a decline in Resident 33's quality of life. Findings: During a review of Resident 33's admission Record (AR), the AR indicated Resident 33 was re-admitted to the facility on [DATE] with diagnosis that included dysphagia (difficulty swallowing), abnormal posture and dementia (a decline in mental ability severe enough to interfere with daily life). During a review of Resident 33's Minimum Data Set (MDS, a resident assessment and care-screening tool), dated 3/7/24, indicated Resident 33's preferred…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 four sampled residents (Resident 55) observed during medication pass (term used to describe the process through which medication is administered [given] to patients) was free of significant medication errors by failing to ensure Resident 55's routinely scheduled medication, Tramadol (a strong opiod [class of drug used to reduce pain] medication used to treat moderate to severe pain that is not being relieved by other types of pain medicines) was administered. This failure had the potential to cause a decline in Resident 55's physiological well-being related to poor management of Resident 55's pain and the potential for Resident 55 to experience withdrawal (physical and mental symptoms that occur after stopping or reducing intake of a drug) symptoms. Findings: During a review of Resident 55's admission Record (AR), the AR indicated, Resident 55 was admitted to the facility on [DATE] with multiple diagnoses including idiopathic…

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