Pomona Vista Care Center

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 1) was provided with comfortable and homelike environment by failing to remove two boxes of canned soda, which did not belong to Resident 1, from Resident 1's nightstand.This deficient practice resulted in Resident 1 feeling upset and Resident 1's private privacy space being violated.Findings:During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness in the arm, leg, and face on one side of the body) following cerebral infarction (loss of blood flow to a part of the brain), and other abnormalities of gait and mobility (abnormal walking patterns, including limping, shuffling, dragging feet, or instability).During a review of Resident 1's History and Physical (H&P, physician's clinical…

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 1) 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 in accordance with the facility's policy and procedure (P&P) titled, Abuse, Neglect, and Exploitation, dated 12/19/2022.This failure resulted in the delay of notification to the Department, the Ombudsman, and to the local law enforcement and had the potential to result in Resident 1 to be subjected to abuse while at the facility.(cross reference F580 and F656)Findings:a. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness in the arm, leg, and face on one side…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a person-centered care plan (a treatment plan that focused on the needs and preferences of a resident or individual) was developed and implemented for one of four sampled residents (Resident 1) to monitor Resident 1's physical and psychosocial well-being after Resident 1 was grabbed on the arm by Resident 4 on 3/2/2026 and Social Services Director (SSD) requested psychology consultation for Resident 1 on 3/3/2026.These deficient practices had the potential to place Resident 1 at risk of not receiving the individualized care services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.(cross reference F580 and F609)Findings:a. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness in the arm,…

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 comprehensive care plans (CP) for two of two sampled residents (Resident 42 and Resident 16) when, A. For Resident 42, a CP was not developed that addressed Resident 42's non-compliance to turning and repositioning. B. For Resident 16, a CP was not developed that addressed Resident 16's Post Traumatic Stress Disorder (PTSD, a mental health condition that can developed after experiencing or witnessing a traumatic event) diagnosis. This deficient practice had the potential to result in unmet individualized needs for Residents 42 and 16 and the potential to affect the resident's physical and psychosocial well-being. (Cross Reference F699) Findings: A. During a review of Resident 42's admission Record (AR), the AR indicated Resident 42 was admitted to the facility 9/3/2024 with diagnoses that included unspecified dementia (a group of conditions, decline in mental ability, that interfere with daily activities), hyperlipidemia (having…

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

Based on observation, interview, and record review, the facility failed to provide nursing care and services to prevent pressure injury (injury to skin and underlying tissue resulting from prolonged pressure on the skin and/or underlying soft tissue usually present over a bony prominence) for one of four sampled residents (Resident 42) when the facility failed to: a. Develop a care plan to address Resident 42's non-compliance to turning and repositioning. b. Ensure staff would follow the same system for turning and repositioning for Resident 42. c. Ensure proper communication of Resident 42's changes in skin condition. These deficient practices incresed the risk for Resident 42 to develop a deep tissue injury (DTI - Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue on the right malleolus. Findings: During a review of Resident 42's admission Record (AR), the AR indicated Resident 42 was admitted to the facility 9/3/2024 with diagnoses that included unspecified dementia (a group of conditions,…

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 2 of 2 sampled residents (Resident 56 and Resident 41), who were fed by enteral feeding tubes (a tube inserted into the digestive system to deliver liquid nutrition when someone cannot eat or drink normally) received appropriate treatment by failure to: a. change the water flush bag for Resident 56 to follow the manufacturer's recommended time of a 24-hour use time. b. clarify a physician's order for oral (PO) medication administration for Resident 56, despite Resident 56 being documented as NPO (nothing by mouth) and receiving medications via gastrostomy-tube (G-tube-a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). c. change the water flush bag for Resident 41 to follow the manufacturer's recommended time of a 24-hour use time. These deficient practices had the potential for Resident 56 and Resident 41 to experience nausea and vomiting…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide respiratory care and services for two of two sampled residents (Resident 20 and Resident 41) when, a. Resident 20's oxygen [colorless, odorless gas] was not on continuously as indicated in Resident 20's care plan (CP). b. Resident 41's nebulizer mask and tubing was not changed in accordance with the facility's Policy and Procedure (P&P) titled, Oxygen Administration. These deficient practices had the potential to result in physical declines to Residents 20 and 41. Findings: a. During a review of Resident 20's admission Record (AR), the AR indicated the facility admitted Resident 20 on 2/28/2025, with diagnoses that included acute (sudden) respiratory failure (when lungs cannot release enough oxygen into the blood, which prevents the organs from properly functioning. It also occurs if the lungs cannot remove carbon dioxide from the blood), chronic obstructive pulmonary disease (COPD- type of obstructive lung disease characterized…

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 completeness of medical records for two of two sampled residents (Residents 2 and 24). This deficient practice had the potential to lead to inconsistent and/or inaccurate treatments provided to Residents 2 and 24. Findings: a. During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was admitted to the facility 10/7/2024 with diagnoses that included lack of coordination, major depressive disorder, and heart failure (condition in which the heart cannot pump enough blood to all parts of the body). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 2/12/2025, the MDS indicated Resident 2's cognition was intact. b. During a review of Resident 24's admission Record (AR), the AR indicated Resident 2 was admitted to the facility 5/31/2022 with diagnoses included hemiplegia/hemiparesis (paralysis [complete or partial loss of muscle function] on one side of the body) and unspecified dementia (a group of conditions, decline in mental ability, that interfere…

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 (the invasion and growth of germs in the body) prevention and control practices designed to provide a safe, sanitary and comfortable environment for 13 of 13 sampled residents (Residents 14, 28, 5, 4, 48, 18, 54, 47, 34, 26, 10, and 30) and the residents (in general) by failing to ensure: a. Personal toiletries and resident care items were labeled with resident names and not stored inside the [NAME] and [NAME] restroom (a restroom that has two doors and is sandwiched between two bedrooms accessible by the residents in both bedrooms) of Residents 14, 28, 5, 4, 48, 18, and of Residents 54, 47, 34, 26, and 10. b. medical supplies, stored in the medication storage room, were not expired. c. staff personal belongings were not stored in the medication storage room. d. the enteral feeding ([also referred to as tube feeding], a way to deliver liquid nutrition directly into the stomach or small intestine through a tube when a…

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

Based on observation, interview, and record review, the facility failed to ensure resident privacy during the provision of personal care for one of two sampled residents (Resident 19). This deficient practice had the potential to cause, or may have caused, psychosocial harm, including embarrassment, loss of dignity, and emotional distress. Findings: During a review of Resident 19's admission Record (AR), the AR indicated the facility admitted Resident 19 on 3/1/2023, and re-admitted the resident on 9/4/2023, with diagnoses including hemiplegia (when one side of a person's body is paralyzed or has no movement, usually because of brain damage, like from a stroke [when blood flow to part of the brain gets blocked or a blood vessel in the brain bursts]) and hemiparesis (weakness on one side of the body with reduced strength and movement) affecting right dominant side, gout (a painful joint condition caused by too much uric acid [a natural waste product in the body when it breaks down certain foods), and repeated falls. During a review of Resident 19's Minimum Data Set (MDS, a resident…

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

Based on observation, interview, and record review, the facility failed to provide good hygiene to one of one sampled resident (Resident 16). This deficient practice had the potential to cause skin infections to Resident 16. Findings: During a review of Resident 16's admission Record (AR), the AR indicated the facility admitted Resident 16 on 6/27/2024, with diagnoses that included dementia (a group of conditions, decline in mental ability, that interfere with daily activities), Alzheimer's disease (irreversible, progressive brain disorder that slowly destroys memory and thinking skills, and eventually the ability to carry out the simplest tasks). During a review Resident 16's Minimum Data Set (MDS - a resident assessment tool), dated 3/21/2025, the MDS indicated Resident 16's cognition (ability to understand and process information) was severely impaired. The MDS indicated Resident 16 had no impairment with the range of motion (ROM, full movement potential of a joint) of both upper extremities (arms and legs). The MDS indicated Resident 16 was dependent on staff with toileting…

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 care and services to prevent weight loss for one of three sampled residents when Resident 43 did not meet the goal of 75-100 % meal intake. This deficient practice had the potential to result in further weight loss and a physical decline to Resident 43. Findings: During a review of Resident 43's admission Record (AR), the AR indicated the facility admitted Resident 43 on 10/10/2024, with diagnoses that included dementia (a group of conditions, decline in mental ability, that interfere with daily activities) and dysphagia (difficulty swallowing). During a review of Resident 43's Minimum Data Set (MDS - a resident assessment tool), dated 4/4/2025, the MDS indicated Resident 43 had moderate impaired cognition and was dependent on staff with all activities of daily living (ADL, term used in healthcare that refers to self-care activities). During a review of Resident 43's Interdisciplinary (IDT, a team of health care professions who work together to establish plans of care for residents) Care Conference…

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

Based on interview and record review, the facility failed to provide trauma-informed care for one of one sampled resident (Resident 16) by not ensuring that the resident received adequate care and services to address their Post-Traumatic Stress Disorder (PTSD-a mental health condition that can develop after someone has experienced a deeply disturbing or frightening event). This deficient practice resulted in inadequate attention to Resident 16's specific trauma-related needs and the potential to affect the resident's physical and psychosocial well-being. Cross Reference F656 Findings: During a review of Resident 16's admission Record (AR), the AR indicated the facility admitted Resident 16 on 6/27/2024, with diagnosis including, PTSD, hypertension (HTN-high blood pressure), and peripheral vascular disease (PVD- a slow progressive narrowing of the vessels [blood flow] to the arms and legs). During a review of Resident 16's Minimum Data Set (MDS - a resident assessment tool), dated 3/21/2025, the MDS indicated Resident 16 had severe cognitive (the ability to think and process…

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 nurse staffing data in, two of two nursing stations (North Station and South Station), was posted in a prominent place readily accessible to residents and visitors. This deficient practice had the potential for residents and visitors to not be aware of the actual and accurate nursing hours to ensure facility had enough staff to provide care during each shift. Findings: During a concurrent observation, interview, and record review on 4/18/2025 at 3:35 PM with Licensed Vocational Nurse (LVN) 2, in the South Station, LVN 2 was asked where the facility's actual staffing schedule was posted. LVN 2 took a green colored binder titled, South Station Daily Assignment and Monthly Schedule (SDAMS), that was kept on the lower counter of the nursing station was reviewed. The lower counter was not visible from the hallway. The nursing staffing schedule for the day shift (7:00AM), dated 4/18/25, was the latest on file. LVN 2 stated, the SDAMS is where the staff checked their assignment. During a concurrent…

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

Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 56) was free from a significant medication error by failing to clarify a physician's order for oral (PO) medication administration, despite Resident 56 being documented as NPO (nothing by mouth) and receiving medications via gastrostomy-tube (G-tube-a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). This failure resulted in the administration of medication without confirming the appropriate route of administration and placed Resident 56 at risk for adverse medication side effects (unwanted, uncomfortable, or dangerous effects that a resident may have due to a medication). Findings: During a review of Resident 56's admission Record (AR), the AR indicated the facility admitted Resident 56 on 3/26/2023, with diagnoses including encephalopathy (a serious health problem that affects brain function or structure), diabetes mellitus (DM, a disorder characterized by difficulty…

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 one locked medicine refrigerator (RM - a refrigerator that is dedicated to storing and keeping the temperature of medicines and biologicals) was maintained under proper temperature controls in accordance with the facility's policy and procedure (P&P) titled, Medication Storage. This deficient practice could potentially lead to degrading and losing the potency (intensity of effect) of the medicines and biologicals which could potentially be harmful and compromise the health, safety, and well-being of the residents. Findings: During an observation on 4/18/2025 at 12:03 PM with the Registered Nurse Supervisor (RN), the facility's RM inside the medication storage room had a supply of medications that included insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) pens and vaccines (medications used to prevent diseases usually given by injection or by mouth). The temperature inside the RM was forty-three point five (43.5) degrees…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to conduct a thorough investigation of an allegation of abuse that occurred between Residents 1 and 2 on 1/18/2025 per the facility's Policy and Procedure (P&P) titled, Abuse, Neglect and Exploitation, by failing to obtain a statement/information from Resident 3 who identified herself as a witness. This failure had the potential to omit possible evidence in the allegation of abuse between Residents 1 and 2. Findings: 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 metabolic encephalopathy (damage or disease that affects the brain) and type 2 diabetes (disorder characterized by difficulty in blood sugar control). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 1/2/2025, the MDS indicated Resident 1 had moderately impaired cognition (ability to think, reason, plan) and required supervision or touching assistance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive Care Plan (CP - document created to identify a patient's needs) in a timely manner to address wandering into resident rooms for one of seven sampled residents (Resident 2). This deficient practice had the potential to leave Resident 2's wandering behavior unaddressed and potentially affecting the safety of Resident 2, other facility residents, and their families. Findings: During a review of Resident 2's admission Record, (AR), the AR indicated Resident 2 was admitted on [DATE] and readmitted on [DATE] with diagnoses including metabolic encephalopathy (damage or disease that affects the brain) and dementia (a progressive state of decline of mental abilities.) During a review of Resident 2's Elopement Risk, (ER) dated 1/8/2025, the ER indicated Resident 2 had goal directed wandering behavior. During a review of Resident 2's Minimum Data Set, (MDS - a resident assessment tool) dated 1/13/2025, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately document in the resident's clinical record when close monitoring and one-to-one supervision was implemented for one of seven sampled residents (Resident 2.) This failure had the potential to result in inconsistency of care for Resident 2. Findings: During a review of Resident 2's admission Record, (AR), the AR indicated Resident 2 was admitted on [DATE] and readmitted on [DATE] with diagnoses including metabolic encephalopathy (damage or disease that affects the brain) and dementia (a progressive state of decline of mental abilities.) During a review of Resident 2's Minimum Data Set, (MDS - a resident assessment tool) dated 1/13/2025, the MDS indicated Resident 2 had severe cognitive impairment (ability to think, reason, plan) and required substantial or maximum assistance (helper does more than half the effort) for toileting and bathing. During an interview on 1/31/2025 at 1:00 PM with the facility's Director of Nursing (DON), the DON…

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 resident's right to remain free from physical abuse (willful infliction of injury, deliberate aggressive or violent behavior with the intention to cause harm) for one of two sampled residents (Resident 2) by failing to protect Resident 2 from being hit by Resident 3. On 8/6/2024, Resident 3 hit Resident 2 on Resident 2's chest. This failure had the potential to result in Resident 2 feeling afraid and not safe while under the care of the facility. Findings: 1. During a review of Resident 2's admission Record (AR), the AR indicated, the facility admitted Resident 2 to the facility on 9/4/2023, with diagnoses including hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) of the right side, personal history of cerebral infarction (also called ischemic stroke, occurs as a result of disrupted blood flow to the brain), and muscle weakness. 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 interview and record review, the facility failed to report an allegation of abuse 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 and Exploitation, dated 12/19/2022, for one of two sampled residents (Resident 1). This failure resulted in the delay of notification to the Department and other officials and had the potential for Resident 1 to be subjected to potential further abuse. 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 including metabolic encephalopathy (brain disease that alters brain function or structure), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and dementia (a group of…

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

Based on observation, interview, and record review, the facility failed to implement its infection prevention and control program for a census of 52 residents by failing to ensure Certified Nursing Assistant (CNA) 1 and CNA 2 performed hand hygiene (cleaning hands by either washing them with soap and water, or by using alcohol-based hand rub [ABHR- liquid, gel, or foam which contains alcohol and applied to hands to kill most bacteria and viruses]) in accordance with the hand hygiene in-service (ongoing employee educational and training program) provided to all staff by the Infection Prevention Nurse (IPN- responsible for coordinating infection prevention and control program activities to prevent, detect, and mitigate communicable diseases and infections within the facility) on 5/5/2024. This failure had the potential to spread infection to all residents and staff in the facility. Findings: During an observation on 7/2/2024 at 11:51 am, CNA 1 removed CNA 1's soiled gloves after CNA 1 provided care to Resident 3. CNA 1 did not wash CNA 1's hands or used ABHR after removing gloves. CNA…

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 monitor and supervise one of three sampled residents (Resident 8) by failing to ensure Resident 8 did not wander (to go about from place to place usually without a plan or definite purpose) into other residents' rooms. This failure had the potential to result in resident-to-resident altercation involving Resident 8 and had the potential to cause injury/harm to Resident 8 and/or other residents. Findings: During a review of Resident 8's admission Record (AR), the AR indicated the facility initially admitted Resident 8 to the facility on [DATE], and readmitted Resident 8 on 12/8/23, with diagnoses that included COVID-19 (minor to severe respiratory illness caused by a virus and spread from person to person), unspecified psychosis (mental disorder causing disconnection from reality), and unspecified dementia with other behavioral disturbance (a group of thinking and social symptoms that interfered with daily functioning). During a review of Resident 8's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 2) was free from physical abuse from Resident 3 who had just hit another resident (Resident 1) by failing to provide a 1:1 (providing one to one continuous nursing or observation care to an individual patient with behavioral problems for a period of time) supervision to Resident 3, in accordance with Resident 3's care plan (CP, provides direction on the type of nursing care an individual needs that include goals of treatment, specific nursing interventions [actions, treatments, procedures, or activities designed to meet an objective] and an evaluation plan), titled The resident has a behavior problem . This deficient practice resulted in Resident 3 hitting Resident 2 after an incident involving Resident 3 who had hit Resident 1 the previous day. Findings: During a review of Resident 1's admission Record (AR), the AR indicated, Resident 1 was admitted to the facility on [DATE] with multiple…

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 (Residents 1, Resident 2) were free from physical abuse from Resident 3 by failing to ensure Resident 3 who was newly admitted to the facility and diagnosed with dementia (a general term to describe a group of symptoms related to loss of memory, judgment, language, complex motor skills, and other intellectual function, caused by the permanent damage or death of the brain's nerve cells, or neurons) was provided and received the appropriate treatment ( specific treatment?) and services to attain or maintain Resident 3 ' s highest practicable physical, mental, and psychosocial well-being. This deficient practice resulted in Resident 1 and Resident 2 being physically abused by Resident 3. Findings: During a review of Resident 1 ' s admission Record (AR), the AR indicated, Resident 1 was admitted to the facility on [DATE] with multiple diagnoses that included spinal stenosis (abnormal narrowing), site…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to readmit Resident 1 back to the facility from the General Acute Care Hospital (GACH) 2 as indicated in the facility's policy and procedure titled, readmission to Facility. This deficient practice violated Resident 1's right to return to the facility. Findings: During a review of Resident 1's admission Record (AR), the AR indicated, the facility initially admitted Resident 1 to the facility on [DATE] and readmitted Resident 1 on 3/19/2024, with diagnoses that included cerebral infarction (stroke - damage to tissues in the brain due to a loss of oxygen to the area), epilepsy (a brain condition that causes repeated seizures), and dementia (the loss of the ability to think, remember, and reason to levels that affect daily life and activities). During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 11/6/2023, the MDS indicated, Resident 1 had the ability to understand others and was understood by…

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 perform neurological checks (neuro checks, an assessment tool that evaluated the brain and nervous system [the body's command center that included the brain, spinal cord, and nerves] functioning) as indicated in the facility's policy and procedure (P&P) titled, Head Injury, for one of two sampled residents (Resident 1), after a change in condition. This deficient practice had the potential to place Resident 1 at risk for any neurological (relating to disorders of the nervous system) issues not being identified. Findings: During a review of Resident 1's admission Record (AR), the AR indicated, the facility initially admitted Resident 1 to the facility on [DATE] and readmitted Resident 1 on 3/19/2024, with diagnoses that included cerebral infarction (stroke - damage to tissues in the brain due to a loss of oxygen to the area), epilepsy (a brain condition that causes repeated seizures), and dementia (the loss of the ability to think, remember, and reason…

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 revise and implement an individualized care plan for two of two sampled residents (Residents 47 and 19). A. The care plan for Resident 47, who was assessed with range of motion (ROM, full movement potential of a joint) and mobility (ability to move) limitations, was not revised to address the further decline in the ROM of both lower extremities. B. The care plan for Resident 19 was not revised to address Resident 19's need to wear hearing aids. These failures had the potential to cause a decline in the Resident 47 and 19's physical and/or psychosocial well-being related to the delay in the delivery of the necessary care and services. Findings: A. During a review of Resident 47's admission Record (AR), the AR indicated the facility initially admitted Resident 47 on 11/22/2023 with multiple diagnoses including type 2 diabetes mellitus (disorder causing elevated sugar level in the blood), Parkinson's disease (brain disorder causing…

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 for two of two sampled residents (Resident 19 and Resident 41) by failing to: a. Ensure Resident 19 was offered her dentures before each meal and facility followed up with Resident 19's dentist timely to obtain the status of dental treatment authorization for a dental procedure. This deficient practice had the potential to cause mouth pain/discomfort, choking, and weight loss for Resident 19. b. Ensure Resident 41's peripheral intravenous (IV, into or within a vein) Heplock (H/L, a medical device catheter placed in a vein to administer medication or fluid into the bloodstream) was changed in accordance with the facility's policy and procedure (P&P), titled Intravenous Therapy. This deficient practice had the potential to result in complications from an old IV access including infiltration (when IV fluid leaked into tissue because of improper catheter placement or dislodgement), phlebitis (inflammation of a vein)…

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 5) nutritional status and progressive weight loss was accurately and consistently monitored and assessed as needed and acted upon promptly. This failure resulted in significant weight loss to Resident 5. Findings: During a review of Resident 5's admission Record (AR), the AR indicated, Resident 5 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including type 2 diabetes mellitus (adult-onset disease in which your blood glucose, or blood sugar, levels are too high) without complications, hemiplegia (paralysis of one side of the body after a stroke) and hemiparesis (weakness or inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing) following unspecified cerebrovascular disease (a group of conditions that affect the blood vessels and blood supply to the brain) affecting the right…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that the medication error rate was less than 5% for two of five sampled residents (Residents 4 and 10) during the medication administration. The medication error rate was 11.11% due to three medication errors in a total of 27 opportunities observed. A. For Resident 4, Licensed Vocational Nurse 5 (LVN 5) failed to verify Resident 4's Metformin (medication prescribed to lower sugar level in the blood) Extended Release (ER, slowly released into the body over a period of time usually 12 or 24 hours) and famotidine (medication prescribed to lower acid production in the stomach and prevent heartburn [stomach acid irritating the food pipe lining and causing burning chest pain]) were crushable and administered in accordance with the professional standards of practice. B. For Resident 10, LVN 2 failed to ensure Licensed Vocational Nurse (LVN ) verified the medication expiration date prior to the administration of diltiazem (medication to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of four sampled residents (Residents 4 and 10) were free of significant medication errors. A. Licensed Vocational Nurse 5 (LVN 5) did not verify Resident 4's Metformin (medication prescribed to lower sugar level in the blood) Extended Release (ER, slowly released into the body over a period of time usually 12 or 24 hours) was crushable and administer in accordance with the professional standards of practice. B. Ensure Licensed Vocational Nurse (LVN) verified the medication expiration date prior to the administration of diltiazem (medication to treat high blood pressure and chest pain) to Resident 10 in accordance with the facility's policy and procedures (P&P). These failures had the potential to cause a decline in Resident 4 and 10's physiological well-being related to the decreased medication efficacy (ability to produce the desired beneficial effect). Findings: A. During a review of Resident 4's admission Record (AR 1), AR 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure: a. Expired medications were not stored in one of one facility Medication Storage room, in accordance with professional standards of practice and the facility's policy and procedure (P&P) titled, Medication Storage. b. Licensed Vocation Nurse 2 (LVN 2) did not prepare expired medication for one of one resident (Resident 10) during medication pass administration. Resident 10's Diltiazem (medication to treat high blood pressure and chest pain) liquid form medication had an expiration date of 4/6/2024. These failures had the potential to result in resident harm and/or residents not getting the full benefits of the medication. Findings: a. During a concurrent observation and interview on 4/18/2024 at 6:30 p.m. in the facility's medication storage room with Registered Nurse (RN), one cabinet labeled House Supply Meds, was inspected. The cabinet had multiple supply of unopened house supply (over the counter) medications with the…

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

Based on observation, interview, and record review, the facility failed to ensure for one of two red buckets (Red Bucket 1, used to wipe contact surfaces for infection prevention and control) located in the kitchen that contained sanitization fluid had adequate concentration levels. In addition, the facility failed to ensure Almond milk and 2% low-fat milk located in one of two kitchen refrigerator (Refrigerator 2) were labeled correctly as indicated in the Refrigerated Storage Quick Reference Guide. This failure had the potential to result in cross contamination (process by which bacteria can be transferred from one area to another), the spread of infections, and physical declines to residents who ingested the facility's food. Findings: During a concurrent observation and interview on 4/15/24 at 9:46 a.m., with the Dietary Services Director (DSD 2), in the facility's kitchen, one opened carton of Almond milk was observed labeled with a use by date of 4/10/24 and one carton of 2% reduced fat milk was observed labeled with a use by date 4/13/24 in Refrigerator 2. DSD 2 stated it was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the resident and/or the responsible party (RP) for three of three sampled residents (Residents 53, 12, and Resident 24) understood the Binding Arbitration Agreement (BAA, contract between the facility and resident/RP requiring disputes to be resolved by a neutral arbitrator [third party decision-maker] instead of a judge or jury in court) signed upon the residents' admission to the facility. This failure had the potential to cause a decline in the residents' psychosocial well-being due to the failure to understand the implications of the signed documents. Findings: a. During a review of Resident 53's admission Record (AR 1), AR 1 indicated, the facility initially admitted Resident 53 on 1/21/2024 with multiple diagnoses including chronic pulmonary edema (excess fluid in the lungs), heart failure, and hypertension (high pressure of blood pushing against the wall of the arteries). During a review of Resident 53's History and Physical (H&P 1),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow infection prevention and control practices and implement interventions to prevent and control the spread of infections in the facility for five of five sampled residents (Residents 12, 159, 3, 15, & 57) in accordance with the facility's policies and procedures (P&Ps) and national health guidelines by failing to implement the facility's P&P on Enhanced Barrier Precautions (EBP, use of gown and gloves for use during high-contact resident care activities for certain resident population) timely for the following residents: A. Res 12 who had an indwelling urinary catheter (IUC, a flexible plastic tube inserted into and retained in the bladder to provide continuous urinary drainage). B. Ensure Treatment Nurse 1 (TXN 1) followed proper infection control practices while providing Resident 12's IUC care in accordance with the facility's P&Ps and professional standards of practice. C. Res 159 who had an IUC. D. Ensure Licensed Vocational…

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 conduct an assessment to determine if self-administration of medications was clinically appropriate for one of one sampled resident (Resident 53) as indicated in the facility's policy and procedure (P&P), titled, Resident Self-Administration of Medication. This failure had the potential in harm and to negatively affect Resident 53's physical well-being due to possible drug-to-drug interactions and unforeseen drug adverse effects. Findings: During a review of Resident 53's admission Record (AR), the AR indicated the facility initially admitted Resident 53 on 1/21/24 with multiple diagnoses including chronic pulmonary edema (excess fluid in the lungs), heart failure, and hypertension (high pressure of blood pushing against the wall of the arteries). During a review of Resident 53's History and Physical (H&P), dated 1/22/24, the H&P indicated Resident 53 had fluctuating capacity to understand and make decisions. During a review of Resident 53's Minimum Data Set (MDS, a standardized 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 interview and record review, the facility failed to follow up with the Department of Health Care Services (DHCS, state-designated authority for Preadmission Screening and Resident Review [PASRR] determinations) for one of two sampled resident (Resident 24) regarding the PASRR process. Resident 24 had a Positive Level I Screening (an initial screening that indicated Resident 24 required a Level II Evaluation, a person-centered evaluation to determine the most appropriate placement and if specialized services were required) on 1/22/24. This failure had the potential to cause a decline in Resident 24's psychosocial well-being due to possible lack of specialized services. Findings: During a review of Resident 24's admission Record (AR), the AR indicated the facility initially admitted Resident 24 on 11/5/22 with multiple diagnoses including Alzheimer's disease (onset date 1/21/24, brain disorder that progressively destroys memory, thinking skills, and ability to carry out simple tasks), anxiety 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 develop a comprehensive plan of care for one of one sampled resident (Resident 22). This failure resulted in the resident not receiving individualized care and had the potential to result in Resident 22 not to maintain the highest practical physical and mental well-being. Findings: During a review of Resident 22's admission Record (AR), the AR indicated Resident 22 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy (brain disease that alters brain function or structure), peripheral vascular disease (reduced blood flow to the limbs [arms and legs]), and unspecified dementia (a decline in mental ability). During a review of Resident 22's History & Physical (H&P) dated 1/30/24, the H&P indicated Resident 22 did not have the capacity to understand and make decisions. During a review of Resident 22's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 1/31/24, the MDS indicated Resident 22…

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

Based on observation, interview, and record review the facility failed to provide a preferred activities for one of one sampled resident (Resident 20) as indicated in Resident 20's Minimum Data Set (MDS, an assessment and screening tool) dated 6/14/23, which indicated Resident 20 liked listening to music. This deficient practice had the potential to result in a decline to Resident 20's physical, mental, and psychosocial well-being. Findings: During a review of Resident 20's admission Record (AR), the AR indicated Resident 20 was admitted to the facility 6/8/21 with diagnoses that included dementia (a decline in mental ability), major depressive disorder, and hypertension (high blood pressure). During a review of Resident 20's Minimum Data Set (MDS, an assessment and screening tool) dated 6/14/23, the MDS indicated Resident 20 was severely impaired in cognitive (ability to understand and process information) skills. The MDS indicated listening to music Resident 20 liked was somewhat important. During a review of Resident 20's care plan (CP), the CP's focus indicated Resident 20…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure hearing aids were made available daily for one of one sampled resident (Resident 19). Resident 19 was hard of hearing. This failure resulted in Resident 19 not being able to hear adequately and had the potential to result in a psychosocial decline to Resident 19. Findings: During a review of Resident 19's admission Record (AR), the AR indicated Resident 19 was readmitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (group of lung diseases that block airflow), anxiety disorder (strong feeling of worry, anxiety, or fear), and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). During a review of Resident 19's History & Physical (H&P), dated 6/29/23, the H&P indicated Resident 19 had fluctuating capacity to understand and make decisions. During a review of Resident 19's physician assistant (PA) visit, dated 3/30/23 & 11/2/23, the PA indicated Resident…

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

Based on observation, interview, and record review, the facility failed to provide the care and services for one of one sampled resident (Resident 12) who had an indwelling urinary catheter (IUC, a flexible plastic tube inserted into and retained in the bladder to provide continuous urinary drainage) in accordance with the facility's policy and procedure (P&P) and professional standards of practice. This failure had the potential to increase Resident 12's risk for catheter-associated urinary tract infection (CAUTI, germs enter and infect the urinary tract through the urinary catheter). Findings: During a review of Resident 12's AR (AR), the AR indicated the facility initially admitted Resident 12 on 11/17/2023 with multiple diagnoses including type 2 diabetes mellitus (disorder causing elevated sugar level in the blood), history of stroke (brain damage due to blocked blood supply to the brain), chronic kidney disease, and obstructive and reflux uropathy (blocked urine flow causing urine to flow back into the kidneys). During a review of Resident 12's History and Physical (H&P),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a safe discharge (when a resident/patient is moved to another facility or location, and return to the original facility is not expected) for 1 of 3 sampled residents (Resident 1) by failing to ensure: 1. Resident 1, who was at risk for elopement (when an individual who is incapable of protecting himself/herself leaves the health care facility unsupervised and undetected) and required supervision or steadying assistance to walk 50 feet with two turns, was discharged to a secured facility (a facility with provisions to prevent elopement, i.e., exit doors are locked). Resident 1's family filed a missing person report. 2. Sufficient preparation and orientation was provided to Resident 1 prior to discharge on [DATE]. These failures resulted in Resident 1 to leave Independent Living Facility 1 (ILF 1, a facility which provided a room, light housekeeping, three meals per day, and a full activities calendar, but personal care and medical services 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.

Based on interviews and record review, the facility failed to develop and implement an individualized care plan for elopement (leaving a facility without notice) for one of three sampled residents (Resident 1) in accordance with the facility's policies and procedures. This failure had the potential to cause inconsistent care and services provided to Resident 1. Cross Reference with F689 Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility initially admitted Resident 1 on 11/2/2023 with multiple diagnoses including cerebral infarction (stroke due to disrupted blood flow to the brain), difficulty walking, lack of coordination, epilepsy (seizure disorder), history of falling, and dementia (group of thinking and social symptoms that interfere with daily functioning). During a review of Resident 1's Elopement Risk assessment (ERA), dated 11/2/2023, the ERA indicated Resident 1 was at risk for elopement due to a history of elopement and wandering (roams around and becomes lost or confused about one's own location) and verbal expression of desire…

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 its policy and procedures titled, Elopement and Wandering Residents, for one of three sampled residents (Resident 1) by failing to: 1. Ensure the interdisciplinary team (IDT, group of staff from different disciplines who work together to share expertise, knowledge, and skills to devise the best plan of care) evaluated the unique factors contributing to Resident 1's high elopement (leaving a facility without notice) risk and developed an elopement risk care plan with person-centered interventions. This failure had the potential to increase Resident 1's risk for elopement which could result in injury or death. Cross Reference with F656 Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility initially admitted Resident 1 on 11/2/2023 with multiple diagnoses including cerebral infarction (stroke due to disrupted blood flow to the brain), difficulty walking, lack of coordination, epilepsy (seizure disorder), history of falling, and dementia (group of thinking 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 seven sampled employees (Licensed Vocational Nurse 1 [LVN 1]) had a complete background check done prior to providing care to the residents as indicated in the facility's Policy and Procedure (P&P), titled, Pre-Employment Screening. This failure had the potential to result in an unsafe environment for the residents residing at the facility. Findings: During a concurrent interview and record review with the Director of Staff Development, a review of LVN 1's employee file was done. The DSD stated, LVN 1 left the faciity on 9/1/21 and was rehire on 3/9/22. The DSD stated, LVN 1 ' s background check upon rehire was done on 4/4/22. During an interview on 10/24/23 at 4:40 p.m., the DSD stated, upon hire, the background check for all staff should be done before they start working in the building. The DSD stated, LVN 1 ' s background check was done on 4/4/22 and her hire date was 3/9/22. A completed background check before working in the building was important to do because we want to make sure there are no criminal…

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, interviews, and record review, the facility failed to report an allegation of sexual abuse to one of three sampled residents (Resident 1) within the required time frame to the State Survey Agency, Ombudsman, and the local law enforcement. This failure had the potential to result in further abuse of Resident 1 or other residents. Findings: During a review of Resident 1's admission Record indicated the facility initially admitted Resident 1 on 2/2/2023, with multiple diagnoses including hypertensive heart disease (chronic high blood pressure that causes structural and functional damage to the heart) with a history of heart attack, viral hepatitis C (infection that causes liver inflammation and damage) with liver cirrhosis (severe scarring of the liver), and type 2 diabetes mellitus (chronic condition in which the body does not produce enough insulin or it resists insulin, causing high blood sugar). During a review of Resident 1's History and Physical, dated 2/6/2023, indicated Resident 1 had the capacity to understand and make decisions. 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.