Landmark Medical Center

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 79) was informed and provided information regarding housing alternatives after discharge. This deficient practice violated Resident 79's rights to be informed of Resident 79's treatment.Findings:During a review of admission Record (AR), the AR indicated Resident 72 was admitted to the facility on [DATE] with diagnoses that included psychosis (a mental health condition characterized by a loss of contact with reality), substance abuse (psychoactive drugs, such as alcohol, pain medications, or illegal drugs), and cigarette nicotine dependance.During a review Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 5/20/2025, the MDS indicated Resident 79 was cognitively intact, had clear speech made self-understand and understood. The MDS indicated Resident 79 was independent with eating, oral and toilet hygiene, dressing, and transfers (moving a resident from one flat surface 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 a radio to one of one sampled resident (Resident 44) in a timely manner.This failure had the potential to lead to psychosocial decline, increased depression, and anxiety for Resident 44.Findings:During a review of Resident 44's admission Record (AR), the AR indicated Resident 44 was admitted to the facility on [DATE] with multiple diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), bipolar type (mental health condition with a mix of symptoms including hallucinations, delusions and mood swings especially periods of very high energy and possibly depressive episodes) and insomnia (sleep disorder characterized by difficulty falling or staying asleep despite having adequate time and opportunity to do so).During a review of Resident 44's Care Plan (CP) regarding activities, initiated 6/10/2025, the CP indicated Resident 44 would be assessed for activities of interest and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure eyeglasses were made available for one of one sampled resident (Resident 1) as indicated in the optometry consultation, dated 10/18/2024, and the care plan (CP) for impaired visual function. This deficient practice had the potential to result in worsening of Resident 1's vision and a psychosocial decline to Resident 1. Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 8/4/2022, with diagnoses that included right eye keratopathy (affects the cornea, the clear front window of the eye), bilateral (left and right) nuclear cataract (clouding/blurry vision), bilateral glaucoma (damages to the nerve of the eye) presbyopia (gradual loss of eye focusing) and schizoaffective disorder (hallucinations and mood swings).During a review of Resident 1's CP titled The resident has impaired visual function initiated on 8/4/2022, the CP's goal indicated for Resident 1 to remain in a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to accurately document a one to one (1:1- continuous observation) monitoring for two hours after an altercation (physical aggression) for one of eight sampled residents (Resident 1). This failure resulted in inadequate documentation of Resident 1's one to one monitoring as ordered by the physician. Findings: A review of Resident 1's admission Record (AR) indicated the resident was readmitted on [DATE] with diagnoses that included schizophrenia (disorder affecting person's ability to think, feel, and behave clearly) and major depressive disorder (persistently depressed mood or loss of interest in activities). A review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 9/10/24, indicated Resident 1 had moderate cognitive (ability to think, reason, and remember) impairment and mobility was independent. A review of Resident 2's AR indicated the resident was admitted on [DATE] with diagnoses that included paranoid…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Certified Nursing Assistant 1 (CNA 1) and Licensed Vocational Nurse 1 (LPT 1) made hourly visual checks for five of five sampled residents (Resident 1, 2, 3, 4, and 6) during the night shift (11 pm to 7 am) as indicated in the facility's Policy and Procedures (P&P). This deficient practice had the potential to result in unmet needs, untimely assistance from staff, and distress to Residents 1, 2, 3, 4, and 6. Cross Reference F678 Findings: During a review of Resident 4's admission Record (AR), the AR indicated the facility admitted Resident 4 on 12/1/2021 with diagnoses that included major depressive disorder (persistent feeling of sadness and loss of interest.) During a review of Resident 1's AR, the AR indicated the facility admitted Resident 1 on 4/15/2022 with diagnoses that included paranoid schizophrenia (mental disorder characterized by abnormal social behavior and failure to understand what is real), bipolar disorder (a serious mental illness that causes unusual shifts in mood, periods of depression and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Certified Nurse Assistant 1 (CNA 1) and Licensed Psychiatric Technician 1 (LPT 1) demonstrated competency during a medical emergency for one of one sampled resident (Resident 1) who was found on the floor unresponsive on [DATE]. Additionally, the facility failed to provide 37 of 74 CPR certificates for direct care staff. This deficient practice had the potential to result in a delay in treatment and delivery of cardiopulmonary resuscitation (CPR - emergency lifesaving procedure, consisting of a combination of chest compressions, mouth- to-mouth, or mechanical breathing [using a device to help someone breaths], performed when the heart stops beating or beats ineffectively and/or to restore breathing) to Resident 1 and had the potential to affect all other residents residing at the facility. Cross Reference F678 Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on [DATE] with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to protect the residents' right to be free from abuse for two of two sampled residents (Residents 1 and 4) as indicated in the facility's policy and procedure (P&P) titled, Elder/Dependent Adult Abuse, by failing to: a. Protect Resident 1 from being kissed on the neck by Resident 2. b. Protect Resident 4 from being spit on and intimidated by Resident 3. These failures resulted in Resident 1 to feel disgusted and for Resident 4 to feel afraid. These failures had the potential to negatively impact the health and well-being of Residents 1 and 4. Findings: a1. During a review of Resident 1's admission Record (AR), the AR indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses including unspecified psychosis (a mental disorder characterized by a disconnection from reality) not due to a substance or known physiological condition, hyperlipidemia (a condition in which there are high levels of fat particles [lipids] 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 to report an allegation of sexual abuse (non-consensual sexual contact of any type with a resident) for one of two 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 Elder/Dependent Adult Abuse, revised 3/22/2024. This failure resulted in the delay of notification to the Department and had the potential for Resident 1 to be subjected to further sexual abuse while at the facility. (Cross Reference F610) Findings: 1. During a review of Resident 1's admission Record (AR), the AR indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses including unspecified psychosis (a mental disorder characterized by a disconnection from reality) not due to a substance or known…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 thoroughly investigate and document the investigation of an allegation of sexual abuse (non-consensual sexual contact of any type with a resident) for one of three sampled residents (Resident 1) in accordance with the facility's policy and procedure (P&P), titled Elder/Dependent Adult Abuse, revised 3/22/2024. This failure had the potential to result in Resident 1 to experience sexual abuse while in the care of the facility. (Cross Reference F609) Findings: 1. During a review of Resident 1's admission Record (AR), the AR indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses including unspecified psychosis (a mental disorder characterized by a disconnection from reality) not due to a substance or known physiological condition, hyperlipidemia (a condition in which there are high levels of fat particles [lipids] in the blood), and insomnia (persistent problems falling and staying asleep). During a review of Resident 1'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.

Based on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 1) was free from physical abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) in according to the facility's policies and procedure (P&P), by failing to ensure Resident 1 did not experience unwanted anal (opening of digestive tract where waste leaves the body) digital penetration (fingers to penetrate [force] someone body) from Resident 2. This deficient practice resulted in Resident 1 experiencing physical and emotional abuse. Findings: During a review of Resident 1's admission Record (AR), indicated Resident 1 was admitted to facility on 8/10/23 with multiple diagnoses including unspecified schizoaffective disorder (a disorder that affects a person's ability to think, feel, and behave clearly), and depression (causes feelings of sadness and/or a loss of interest in activities once enjoyed). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 1 and Resident 3), were free from abuse (deliberately aggressive or violent behavior with the intention to cause harm) in accordance with the facility's policy and procedure (P&P) titled Physical Assault and the facility's lesson plan titled, Elder and Dependent Adult Abuse, Prevention and Policy when, a. On 8/16/2024, Resident 2 inappropriately touched Resident 1's vaginal area (female private area). b. On 8/16/2024, Resident 4 pushed Resident 3 on the back. This deficient practice resulted in Resident 1 feeling uncomfortable and Resident 3 feeling scared and unsafe at the facility. Additionally, the deficient practice had the potential to result in psychosocial declines to Residents 1 and 3. Findings: a. During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 11/8/2023 with diagnoses that included schizophrenia (a serious mental health…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to protect the residents' right to be free from physical abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) for two of four sampled residents (Residents 1 and 2) by failing to: a. Protect Resident 1 from being pushed by Resident 2. b. Protect Resident 2 from being pushed by Resident 1. As a result, on August 11, 2024, Residents 1 and 2 were involved in an altercation. Resident 2 pushed Resident 1 and Resident 1 pushed Resident 2 back, resulting in both residents falling to the floor. This failure resulted in Resident 1 to experience pain and to sustain an abrasion (a superficial rub or wearing off the skin) to Resident 1's right forearm. This failure resulted in Residents 1 and 2 being subjected to physical abuse while under the care of the facility. Findings: a. During a review of Resident 1's admission Record (AR), the AR indicated, Resident 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to provide documented evidence for five of 18 sampled residents (Residents 24, 48, 89, 9, & 59) and/or their legal representative (RP) were informed and/or provided written information regarding Advance Directives (AD, legal document, which specifies the health-related actions in accordance with the resident's wishes, that is executed when the resident is no longer able to make decisions for himself/herself due to illness or incapacity). These failures had the potential to result in violation of the residents' right to formulate ADs and the potential for the residents to receive inappropriate or medically unnecessary care and/or treatment. Findings: a. During a review of Resident 24's admission Record (AR), the AR indicated the facility initially admitted Resident 24 on 8/4/2022 with multiple diagnoses including schizoaffective disorder (mental illness marked by a mix of symptoms of hallucinations [perceptual experiences in the absence of real external…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interviews, and record review, the facility failed to prevent physical abuse (willful infliction of injury that includes, but is not limited to, hitting, slapping, punching, biting, and kicking) for three of six sampled residents (Residents 73, 87, & 57), who were involved in resident-to-resident altercations, when, A. For Resident 73, Resident 87 hit Resident 73's face on 7/29/2024. B. Resident 87, who was on 1:1 monitoring (continuous observation), got hit on the face when Resident 73 hit Resident 87 back with a closed fist on 7/29/2024. C. For Resident 57, the facility failed to provide an abuse-free environment on 8/6/2024. These failures had the potential to result in a decline in the residents' physical and/or psychosocial well-being. Findings: A. During a review of Resident 73's admission Record (AR 1), AR 1 indicated the facility initially admitted Resident 73 on 6/18/2024 with multiple diagnoses including schizoaffective disorder (mental illness marked by a mix of symptoms 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 develop and implement an individualized person-centered care plan (CP) for two of two sampled residents (Resident 44 and Resident 10) as indicated in the facility's policy and procedures (P&P) when, a. Resident 10's High Risk for Falls CP was not updated or addressed falls that occurred on 12/21/2023, 1/4/2024, 1/15/2024, 4/17/2024, 4/24/2024 and 7/7/2024. b. Resident 44 did not have an individualized CP that addressed Resident 44 being a high risk for falls and Resident 44 being legally blind. These failures had the potential to result in unmet individual needs for Residents 10 and Resident 44 and the potential to affect the resident's physical well-being. Additionally, there was a potential for Resident 10 and 44 to receive inaccurate or inconsistent provision of treatments and services. Findings: a. During a review of Resident 10's admission Record (AR) indicated Resident 10 was admitted to the facility on [DATE] with diagnoses that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care and services to prevent a fall (move downward, typically rapidly and freely without control, from a higher to a lower level) for one of one sampled resident (Resident 84) who was assessed as high risk for fall, by failing to: 1. Ensure facility staff provided supervision/monitoring to Resident 84 to prevent recurrent (repeated) falls. 2. Ensure Resident 84's care plan (CP) for falls, titled, High Risk for Falls, dated 1/21/2024 had specific interventions to address Resident 84's recurrent falls. 3. Ensure Resident 84's CP was revised with new interventions after the resident's recurrent falls. As a result, on 6/19/2024 at 8:45 AM Resident 84 sustained a non-displaced fracture (a broken bone that retains its alignment) neck of the second (2nd) and third (3rd) metatarsals (five long bones in the foot connecting the ankle to the toes) on the left foot, while under the care of the facility. Cross reference F657 Findings: During 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 interviews and record review, the facility failed to ensure the facility had a Registered Nurse (RN) at least 8 consecutive hours a day for 7 days a week for one of 10 sampled dates in July 2024 (7/28/2024). This failure had the potential to cause a decline in the residents' physical and/or psychosocial well-being related to insufficient supervision, monitoring, and coordination of care and services by an RN. Findings: During an interview on 8/7/2024 at 11:41 AM, the Director of Nursing (DON) stated another RN, other than the DON, was necessary to assist the charge nurses with supervision and monitoring of residents, since the facility has many resident incidents. The DON stated the RN was necessary to assist resident admissions and discharges to ensure all the care and services, including medications, were coordinated prior to transfers to board and care facilities. During an interview and concurrent review of staffing assignment on 8/7/2024 at 04:05 PM with the DON, the staffing assignment and RN timecards were reviewed. The DON stated on 7/28/2024, there was no RN, who…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure three of five sampled residents (Residents 41, 23, and 66) did not receive unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) by failing to: A. Accurately monitor the specific target behaviors for Resident 41's Lithium (medication used to stabilize mood), Prazosin (medication used to manage and treat hypertension, usually prescribed to reduce nightmares and improve sleep in residents suffering from post-traumatic stress disorder [PTSD, persistent mental disorder due to an extremely stressful or terrifying event]), Vistaril (antihistamine used to treat anxiety [excessive and persistent feelings of worry, fear, dread, and uneasiness that interfere with daily life]), and Trileptal (anticonvulsant used relieve mania [extremely elevated and excitable mood with excessive enthusiasm and overactivity], such as restlessness, hyperactivity, and insomnia) medications. B. Ensure Resident…

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

Based on observations and interviews the facility failed to ensure two of two medication storage rooms had thermometers or thermostats and failed to ensure temperatures and humidity was properly monitored and maintained as indicated in the facility's policy and procedures (P&P), titled, Medication Storage in the Facility, and Storage of Medication. This deficient practice had the potential to result in the loss of strength and integrity of stored medications, and the potential for residents requiring medications from the two medication storage rooms to receive deteriorated or ineffective medications. Findings: During an observation, on 8/6/2024 at 1:04 PM, in the [NAME] Nursing Station Medication Storage Room there was no wall thermostat or thermometer observed in the room. During an interview on 8/6/2024 at 1:20 PM with Licensed Psychiatric Technician (LPT) 1, LPT 1 stated the room temperature inside the [NAME] Nursing Station Medication Storage Room was not known, as there was no room thermometer and the licensed staff did not document the room temperature. LPT 1 stated sometimes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 minimum food holding temperature on the kitchen steam table was maintained at required temperature. This failure had the potential to affect the palatability (taste) of food and placed the residents at risk for food borne illness (illness from ingesting contaminated food). Findings: During a concurrent observation of the facility's kitchen and interview with the Dietary Supervisor (DS) on 8/9/2024 at 11:38 AM red enchilada sauce was held on the steam table at 120 degrees Fahrenheit. The DS stated food on the steam table were held between 155-165 degrees Fahrenheit. The DS stated 135 degrees Fahrenheit is the required holding temperature of food on the steam table. During an interview on 8/9/2024 at 12:12 PM with the DS, the DS stated the steam table holding temperature was important to stop bacterial growth and prevent foodborne illness. The DS stated the DS was unsure when was the last steam table calibration/service (comparing a device's measurement values to a known standard) done. The DS was not…

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

Based on observation, interview, and record review, the facility failed to notify the representative of one of one sampled resident (Resident 44) when Resident 44's physicians recommended cataract (clouding of the normally clear lens of the eye) surgery for Resident 44. This deficient practice resulted in a delay of informing Resident 44's representative of the needed eye treatment and/or services for Resident 44 and prevented Resident 44's representative from being included in decision making regarding Resident 44's plan of care. This deficient practice had the potential to negatively affect Resident 44's quality of life from Resident 44's untreated cataract. Findings: During a review of Resident 44's Administration Record (AR), the AR indicated, the facility admitted Resident 44 to the facility on 8/31/2023, with a diagnoses that included schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), cataract, tributary (branch) retinal (part of the eye that receives light) vein occlusion (blurry vision or vision loss), and legal blindness (unable…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safe and homelike environment for one of two sampled residents (Resident 48) when Resident 48's room bed light's pull-cord switch (pull chain) was not in working condition. This deficient practice had the potential to result in compromised safety to Resident 48 and made the resident feel depressed. Findings: During a review of Resident 48's admission Record (AR), the AR indicated, Resident 48 was admitted to the facility on [DATE] with multiple diagnoses including other psychoactive substance abuse, uncomplicated and insomnia (persistent problems falling and staying asleep), unspecified. During a review of Resident 48's Minimum Data Set (MDS, an assessment and screening tool), dated 11/21/2023, the MDS indicated, Resident 48's cognitive (ability to think and process information) skills for daily decision making was moderately impaired (decisions poor; cues/supervision required). During a review of Resident 48's History of Present…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 notify the Ombudsman (an official, public advocate, helps to resolve issues between parties through various types of informal mediation) regarding one of two sampled resident's (Resident 96) transfer/discharge. This failure had the potential to result in violation of Resident 96's rights regarding appropriate discharge and/or transfer and the potential for the Ombudsman to not be able to advocate for Resident 96. Findings: During a review of Resident 96's admission Record (AR), the AR indicated the facility admitted Resident 96 on 10/18/2022 with diagnoses that included schizophrenia (a chronic [long standing] and severe mental disorder that affects how a person thinks, feels, and behaves characterized by loss of contact with the environment) and post-traumatic stress disorder (PTSD - a mental health condition triggered by a terrifying event - either experienced or witnessed). During a review of Resident 96's Minimum Data Set (MDS-a standardized assessment and care planning tool), dated 4/16/2024, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to revise the Comprehensive Care Plan (CP) for falls following recurrent/repeated fall incidents for one of one sampled resident (Resident 84). This failure had the potential to result in an avoidable fall and injury to Resident 84. Findings: During a review of Resident 84's admission Record (AR), the AR indicated Resident 84 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder (a mental condition that causes both a loss of contact with reality (psychosis) and mood problems), autonomic nervous system disorder (condition that causes dizziness and fainting when standing) and repeated falls. During a review of Resident 84's CP titled, High Risk for Falls (as identified on the Fall Risk Assessment) initiated on 1/21/2024, the CP indicated the following: -On 2/1/24- Resident 84 had a witnessed fall to bilateral knees. - On 2/6/24- Resident 84 had a high fall risk assessment. -On 2/19/24- Resident 84 had a witnessed fall 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 one of five sampled residents' (Resident 49) did not continue to experience progressive weight loss by failing to reassess Resident 49, provide meal intake encouragement for Resident 49 to consure 80 to 100% of Resident 49's meal, provide Nutrition Education Group every Saturday, and provide a banana for lunch and dinner in Resident 49's meal tray in accordance with the physician's order (PO), Resident 49's care plans (CP), and the facility's policy and procedures (P&P). These failures resulted in continued weight loss to Resident 49. Resident 49 lost 13.2 pounds (lbs. unit of weight) in six consecutive months from 3/2024 to 8/2024. Findings: During a review of Resident 49's admission Record (AR), the AR indicated, Resident 49 was admitted to the facility on [DATE] with multiple diagnoses including schizoaffective disorder (a mental illness that combines symptoms of schizophrenia [a serious mental health condition that affects how…

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

Based on interview and record review, the facility failed to ensure a medication regimen review (MRR- a thorough evaluation of a resident's medication regimen to promote positive outcomes and minimize adverse consequences and potential risks associated with medication) was completed by a licensed pharmacist monthly and failed to ensure the licensed pharmacist identified medication irregularities (refers to use of medication that is inconsistent with accepted standards of practice, not supported by medical evidence, and/or interferes with achieving the intended outcomes) for one of five sampled residents (Resident 23) on psychotropic medications (drugs that affect brain activities associated with mental processes and behavior). This failure had the potential to result in Resident 23 receiving unnecessary medication and could lead to increased side effects from duplicate medication therapy (practice of prescribing multiple medications for the same indication or purpose without a clear distinction of when one agent should be administered over another). Findings: 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 follow infection control practices and ensure one of one sampled resident's (Resident 8) closet, was maintained orderly and failed to ensure Resident 8's pile of clean clothes did not spill out (overflow) of Resident 8's closet and did touch the floor. This deficient practice had the potential to result in infection to Resident 8 and for Resident 8's clothes to become a breeding ground for dust mites and other allergens (a substance that could trigger an allergic reaction [a damaging immune response by the body to a substance]) that could potentially impact the health of Resident 8. Findings: During a review of Resident 8's admission Record (AR), the AR indicated, Resident 8 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including schizoaffective disorder (a mental illness that combines symptoms of schizophrenia [a serious mental health condition that affects how people think, feel and…

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

Based on interview and record review, the facility failed to ensure one of five sampled resident's (Resident 44) responsible party (RP) was provided education regarding the benefits and potential risks associated with the COVID-19 (a respiratory viral infection that affects primarily the lungs and result in cough and difficulty breathing) vaccine prior to administration of the vaccine to Resident 44. This deficient practice had the potential to result in Resident 44's RP not to make an informed decision due to the facility not providing education regarding the benefits, risks, and potential side effects associated with the vaccine, or the opportunity to accept or refuse the vaccine. Findings: During a review of Resident 44's admission Record (AR), the AR indicated Resident 44 was admitted to the facility 8/31/2023 with a diagnoses that included schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), cataracts (clouding of the normally clear lens of the eye), tributary retinal vein occlusion (blurry vision or vision loss), and legal blindness…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to protect a residents' right to remain free from physical abuse (willful infliction of injury, deliberate aggressive or violent behavior with the intention to cause harm) for three of eight sampled residents (Residents 1, 3, and 5) by failing to: a. Protect Resident 1 from being pushed by Resident 2. On 5/31/2024, Resident 2 pushed Resident 1 on Resident 1's left arm. b. Protect Resident 3 from being punched by Resident 4. On 6/1/2024, Resident 4 punched Resident 3 on Resident 3's right cheek. c. Protect Resident 5 from being punched by Resident 6. On 6/4/2024, Resident 6 punched Resident 5 repeatedly on Resident 5's face and forehead. This failure had the potential to result in Residents 1, 3, and 5 feeling afraid and not safe while under the care of the facility. Additionally, the failure resulted in bruising, swelling, and pain on Resident 5's forehead. Findings: a. During a review of Resident 1's admission Record (AR), the AR 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 report allegations of abuse for one of four sampled residents (Resident 7) on 2/11/2023 and on 5/8/2023, 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 Elder/Dependent Adult Abuse, revised 1/19/2018. This failure resulted in the delay of notification to the Department and had the potential for Resident 7 to be subjected to further abuse. Findings: During a review of Resident 7's admission Record (AR), the AR indicated, Resident 7 was admitted to the facility on [DATE] with diagnoses including paranoid (where a person feels distrustful and suspicious of other people) schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), major depressive disorder (a mental health disorder…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and CNA 2 accurately documented the resident's location every 15 minutes for one of four sampled residents (Resident 1). This deficient practice resulted in inconsistencies and inaccurate in Resident 1's medical record. Cross Reference: F689 Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 to the facility on [DATE], with diagnoses that included schizoaffective disorder (a mental disorder characterized by abnormal thought processes and an unstable mood), anxiety disorder (persistent feeling of dread or panic that can interfere with daily life), and major depressive disorder (common and serious illness that negatively affects how one feels, thinks and acts). During a review of Resident 1's Physician Order (PO), dated 1/8/2024, the PO indicated an order for staff to monitor Resident 1 Q:15 minutes (every 15 minutes), every shift related to safety.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow a medical doctor's (MD) order for one of nine sampled residents (Resident 7) when Resident 7 had an active MD order for a Buddy Splint (bandaging a damaged or fractured finger together with a healthy, uninjured finger for support) for the left fourth and fifth finger for a nondisplaced fracture (bone is cracked but not broken all the way) of the left fifth finger. This failure had the potential to result in delayed healing for Resident 7's left fifth finger. Findings: During a review of Resident 7's admission Record (AR), the AR indicated Resident 7 was originally admitted to the facility on [DATE], with diagnoses including but not limited to a nondisplaced fracture of the proximal (near center of the body) phalanx (bones in the fingers or toes) of the left little finger with delayed healing, deformity of unspecified fingers, and schizoaffective (mental disorder characterized by abnormal thought processes and an unstable mood)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 there was a Registered Nurse (RN), who worked eight (8) hours a day from Monday to Friday and ensure the Director of Nursing (DON) was not used as a Supervisor or Charge Nurse in this 95 bed skilled nursing facility. This deficient practice had the potential for the residents not to have adequate supervision and appropriate intervention which can only be provided by a Registered Nurse. Findings: A review of the facility's Supervisor Staffing Schedule for the current month and one month prior to the recertification survey was reviewed with the Director of Staff Development (DSD) and the director of Nursing (DON) on 3/10/2022 at 10:51 am. The work schedule indicated the DON worked five days a week as the RN/DON of the facility. In a concurrent interview, the DON stated the facility did not have an RN waiver (a document to assure that sufficient qualified nursing staff are available daily to meet resident's needs for nursing care in a manner and in an environment which promotes each resident's physical, mental 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 failed to follow the facility's policy and procedure on Posting of Direct Care Service Hours Per Patient Day (DHPPD) by failing to: 1. Post accurate staffing information of actual hours worked by the staff directly responsible for resident care per shift, every day, and failed to post the nurse staffing information for two of two units (West and East units). 2. Complete information in the Census and DHPPD for 39 of 90 days (2 days in January, 2022, and 28 days in February, 2022, and 9 days in March 2022). These deficient practices could misled the residents and visitors and may result in inappropriate nursing care. Findings: a. During the initial tour of the facility with the Infection Preventionist Nurse (IPN) on 3/7/2022 at 10:23 a.m., the nurse staffing information dated 2/25/2022, was observed outside of the glass window in the nurses' station [NAME] unit. There was no nurse staffing information posted as of 3/7/2022, in the [NAME] and East units of the facility. In the inter lobby bulletin board, the nurse staffing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 b. A review of Resident 58's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses that included benign prostatic hyperplasia (BPH- prostate gland enlargement; an enlarged prostate gland can cause uncomfortable urinary symptoms such as blocking the flow of urine out of the bladder). A review of Resident 58's Physician's Order Summary Report, dated 10/7/2021, indicated the physician prescribed Tamsulosin HCL capsule ,0.8 milligrams (mg- a unit of measurement) by mouth one time a day. A review of Resident 58's consultant pharmacist's Medication Regimen Review Report dated 12/2/2021 indicated the consultant pharmacist made a recommendation to the attending physician to give the medication at bedtime to minimize the risk for falls. Further review of the consultant pharmacist's recommendation indicated under the Response section, a note was documented as, MD notified, continue with current order. The response did not indicate the rationale why the physician did not change the…

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

Based on observation, interview and record review, the facility failed to store and/or prepare food under sanitary conditions by failing to: a. Ensure two opened plastic bottles containing red liquid in the walk- in refrigerator and one bin of dried green peas in the dry storage area were labeled and dated. This deficient food handling practices had the potential for the facility to serve expired food to the residents that could lead to illness. b. Ensure one of two red buckets containing a chemical sanitizing disinfectant solution (Bucket 2) meets acceptable parameters for Quaternary (QAC, sanitizer used for food service areas) disinfection. This deficient practice had the potential to not fully sanitize equipment and utensil that can lead to contamination and infection. Findings: a. During a follow up kitchen observation and concurrent interview on 3/9/2022 at 11:50 am with the Dietary Supervisor (DS), two opened plastic bottles containing red liquid were unlabeled and stored in the facility's walk-in refrigerator. On the same observation, one bin of dry round green peas 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 to provide nursing care and treatment in accordance with the physician's order and the facility's policies and procedures for one of 19 sampled residents (Resident 67) by failing to: 1. Ensure Resident 67 received insulin (medication to lower the blood sugar) injection per the physician's order. 2. Rotate Resident 67's insulin injection sites in accordance with the facility's policy and procedure. These deficiency practices resulted in Resident 67 did not received one insulin injection as the physician order and had potential for Resident 67's insulin absorption decrease due to staff did not rotate the resident's insulin injection sites. Findings: a. A review Resident 67's admission Record indicated the resident was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included schizoaffective disorder (a combination of symptoms include delusions, hallucinations, depressed episodes, and manic periods of high energy)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 two sampled residents (Resident 5), who was incontinent (any void that occurs involuntarily) of bladder received services and assistance to maintain continence and/or restore continence to the extent possible. This deficient practice had the potential for Resident 5 to decline in bladder continence. Findings: A review of Resident 5's admission record indicated the resident was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder (a mental disorder effecting how a person thinks and feels) and urinary incontinence (loss of bladder control). A review of Resident 5's Minimum Data Set (MDS, resident assessment and care-screening tool), dated 2/18/2022, indicated the resident was cognitively ( ability to understand) intact, was independent with bed mobility, transfers, dressing and toilet use. The MDS indicated the resident was occasionally with urinary incontinence. A review of Resident 5's care plan, titled…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 35) received adequate monitoring for the use of a Geodon (antipsychotic medication used to treat mental disorder) as ordered by the physician and as indicated in the facility's policy. This failure had the potential for the resident to receive unnecessary medication and develop side effects resulting from the medication. Findings: A review of Resident 35's admission Record, indicated the resident was admitted to the facility on [DATE] with diagnoses that included schizophrenia (a mental disorder effecting how a person thinks and feels) and insomnia (inability to sleep). A review of Resident 35's Minimum Data Set (MDS, a resident assessment and care-screening tool), dated 12/7/2021, indicated the resident's cognitive (ability to understand) skills were intact and the resident was independent with bed mobility, transfers, dressing eating and toilet use. A review of Resident 35's Physician'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, facility's staff failed to ensure the content of the Medication Administration Record (MAR) was accurately completed for 1 of 19 sampled residents (Resident 67). Quality Assurance Nurse 1 (QAN 1) signed and dated Resident 67's MAR to indicate she administered the insulin (medication to lower blood sugar) and checked the resident's blood glucose/blood sugar (accucheck) on 3/3/22, at 6: 45 AM when she was not working at the facility on 3/3/22 at 6: 45 AM. This failure resulted in Resident 67's MAR was altered with inaccurate information. Findings: A review Resident 67's admission Record indicated the resident was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included schizoaffective disorder (a combination of symptoms include delusions, hallucinations, depressed episodes, and manic periods of high energy) and type 2 diabetes mellitus (high blood sugar). A review Resident 67's Physician Order Summary Report, dated 3/4/2020,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 precautions to promote health and safety of residents and prevent possible cross-contamination for one of two licensed nurses (Licensed Vocational Nurse 2 [LVN2] ). LVN 2 was observed with long and acrylic (nail enhancements made by combining a liquid acrylic product with a powdered acrylic product) nails while preparing medications for residents in the East Nursing Station. This deficient practice had the potential to result in the transmission of healthcare associated infection to residents receiving care from LVN 2. Findings: During a medication pass observation on 3/9/2022, at 7:53 am, LVN 2 prepared medications for the residents in the East Nursing Station. While preparing medications for the residents, LVN 2 had long acrylic nails, about one centimeter (cm) from the tip of her natural nails. LVN 2 washed her hands after she administered medications to four to five residents. LVN 2 only scrubbed the palm and the back of the hands. LVN 2 did not clean under her fingertips or the nail beds. 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.