Shasta View Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement their Infection Control Program policies and procedures for controlling the spread of a communicable disease and infection when four of seven sampled residents (Resident 4, 5, 6 and Resident 7), tested positive for Influenza A (influenza, a contagious respiratory illness caused by the influenza), and all residents in close contact were not tested in a timely manner, in accordance with the facility's infection control policy. This failure put the residents, staff and families at risk for contracting Influenza A infections and had the potential to result in serious negative clinical outcomes for this vulnerable population.Findings: The facility's policy revised 1/2026, titled, Influenza Exposure Control, was reviewed and indicated the purpose of this policy to establish procedures for prevention of and controlling exposure to influenza (a contagious respiratory illness caused by the influenza virus). The facility shall take a multifaceted…

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 a wound care plan for one of three sampled residents, (Resident 1) when a new physician wound care order was prescribed for a wound vacuum-assisted closure (wound vac, medical device that uses gentle, constant suction to heal complex wounds), to be placed and maintained to the left hip pressure ulcer (a deep wound caused from pressure to the area). This failure had the potential for Resident 1's wound care not to be managed appropriately which could result in discomfort, further deterioration of the wound, and possible infection and hospitalization. Findings: The facility's policy revised 2025, titled, Care Plan Revisions Upon Status Change, was reviewed and indicated the purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. The care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect two of five sampled residents, (Resident 1 and Resident 2) from financial abuse, manipulation and exploitation when:1.The Activity Assistant (AA) J played on Resident 1's sympathy and manipulated Resident 1 out of $800, and promised services she never delivered. 2.AA J loaded Resident 2's bank card onto her personal well-known online shopping website to buy her coffee creamer, when the facility could have bought the coffee creamer for Resident 2, without using her bank card. These failures caused Residents 1 and 2 anxiety, embarrassment, and humiliation and the potential for negative emotional and psychosocial outcomes. Findings: The facility's policy revised 2025, titled, Transactions Involving Resident Funds, was reviewed and indicated it is the practice of this facility that anytime there is a transaction involving resident funds, the resident must be provided with a receipt of such transaction. Copies of each transaction are filed 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 thoroughly investigate a financial abuse allegation and report the results of their investigation within five (5) days to the California Department of Public Health (CDPH) for one of five sampled Residents. (Resident 1)Refer to F600 This failure had the potential to result in further financial abuse to other residents.Findings: The facility's policy revised 2025 titled, Abuse, Neglect and Exploitation, was reviewed and indicated, Investigation of Alleged Abuse, Neglect and Exploitation, will include the following: An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Written procedures for investigations that are included: Identifying staff responsible for the investigation; exercising caution in handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence); Investigation of different types of alleged violations;…

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 reviews, the facility failed to appropriately implement their infection control program to mitigate the spread of COVID-19 (symptoms include fever, fatigue, cough, breathing difficulties, loss of smell, and taste). Both Certified Nursing Assistant (CNA) A and Activity Assistant (AA) did not adhere to the necessary precautions for isolation rooms when they did not follow the proper procedures for putting on or taking off Personal Protective Equipment (PPE, masks, gowns, gloves and eye protection) as per the facility policy.These lapses in following standard protocols posed a significant risk by potentially facilitating the development and transmission of COVID-19 within the facility. This could lead to severe adverse consequences for residents, staff, and visitors. During a record review of facility policy titled COVID-19 Prevention, Response and Reporting dated 2024, indicated Healthcare Personnel who enter the room of a resident with suspected or confirmed SARS-CoV-2…

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 out of three sampled residents (Resident 1) was fully informed of treatment that was provided when the consent form for a psychotropic medication (a medication that alters mood and behavior), was missing important information and not complete. This violated Resident 1's rights to be fully informed of treatment and could negatively affect psychosocial well-being.Findings: A review of the facility's undated policy and procedure (P&P) titled, Use of Psychotropic [medication that affected how the brain worked] Medications, indicated, the resident would be fully informed prior to initiating or increasing a psychotropic medication. A review of the admission Record, dated 8/23/24, indicated, Resident 1 was admitted to the facility on [DATE] with the diagnoses bipolar disorder (extreme shifts in mood, energy, thinking, and behavior) and borderline personality disorder (long term pattern of emotional instability and impulsive behaviors). 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 interview and record review the facility failed to ensure one out of three sampled residents (Resident 1) was provided with appropriate Preadmission Screening and Resident Review (PASARR, a screening, that was done prior to admission to the facility or as needed, and screened residents for possible serious mental health illness) when: The PASARR completed prior to facility admission did not accurately reflect Resident 1's serious mental health illnesses (SMHI); and The facility did not follow up on a subsequent PASSAR that indicated a Level 2 screening (a State agency performed a comprehensive evaluation and made recommendations for care and services) was required. These failures had the potential to cause a decline in psychosocial well-being or cause a delay in required mental health services. Findings: 1. A review of the facility's undated policy and procedure (P&P) titled, Resident Assessment-Coordination with PASARR Program, indicated, the facility would coordinate assessments prior to admission 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 one of three sampled residents (Resident 1) rights were protected when the facility attempted to transfer Resident 1 to another facility out of the area without his permission, or the permission of his Responsible Party (RP). This failure caused Resident 1 to feel anxious and had the potential to result in emotional stress, embarrassment, feelings of neglect, and the potential for negative clinical outcomes. Findings: During a review of the facility's policy revised 2025, titled, Resident Rights, indicated the resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. This facility's policy also indicated self-determination: The resident has the right to, and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to: The resident has a right to choose…

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 five of 15 sampled residents (Resident 1, 2, 4, 7, and Resident 15) had a safe, comfortable and home like environment when the facility air conditioning was not working adequately.This failure caused restlessness, irritability, increased anxiety (a feeling of fear, dread, and uneasiness), insomnia (loss of sleep) and the potential for negative clinical outcomes.Based on observation, interview, and record review, the facility failed to ensure five of 15 sampled residents (Resident 1, 2, 4, 7, and Resident 15) had a safe, cool, and home-like environment when the facility's air conditioning was not working effectively. This failure caused restlessness, irritability, increased anxiety (a feeling of fear, dread, and uneasiness), insomnia (loss of sleep) and the potential for negative clinical outcomes.Findings: A review of the facility's policy revised 8/2024, titled, Loss of Heating or Cooling, indicated it is the policy of this…

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 nursing schedule review, the facility failed to ensure that there was a Registered Nurse (RN) on duty 8 hours per day, 7 days a week. This failure had the potential to adversely affect oversight and direction regarding resident's quality of care and quality of life directly impacting overall health and well-being of the residents. Findings: A review of the Payroll Based Journal (PBJ, an electronic system for facilities to submit staffing information), for Fiscal Year Quarter 2 / 2024: (January 1-March 31), indicated the facility had no registered nurse (RN) on duty for: 1/13/24 Saturday (Sa), 1/27/24 (Sa), 1/28/24 Sunday (Su), 2/3/24 (Sa), 2/4/24 (Su), and 3/17/24 (Su). During an interview on 6/24/25 at 10:11 am, the Interim Director of Nursing (IDON) confirmed, the facility did not have a RN for the above stated time periods.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary conditions were met in the kitchen when: the blender was not air dried, two of four non-stick coated frying pans did not have a cleanable surface, and the hood over the stove had greasy, black debris on it and was not clean. These failures had the potential to place the 52 residents who received food prepared in the facility kitchen at risk for foodborne illness. Findings: A review of the facility's policy titled, Kitchen Hood Inspection and Cleaning, undated with a copyright of 2025, indicated, the kitchen hood exhaust system will be properly cleaned and maintained in order to support the kitchen hood fire suppression system to foster a safe and healthful environment . A record review of the, Diet Order Tally Report on 6/17/25, indicated there were 15 residents with mechanically soft diets (chopped food), four with puree diets (ground or liquid texture), and 33 residents on regular diets, for a total of 52 residents that the kitchen prepared food for. During an observation 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.

Based on observation, interview, and facility document review, the facility failed to ensure essential equipment was maintained in safe operating condition when the walk-in freezer had not kept frozen food frozen and there was excessive ice build-up on the freezer floor. These failures had the potential for the freezer to not function in the way it was intended which could lead to contamination of food, and in turn food-borne illnesses for the 52 residents who received food prepared by the kitchen. Excessive ice build up could pose a safety hazard and accidents for vendors and employees who enter the walk-in freezer. Findings: According to the USDA Food Code 2022 Section 4-501.11, Equipment shall be maintained in good repair and proper adjustment. On 6/16/25 at 10:25 am, an observation of the walk-in freezer and concurrent interview was conducted with the Certified Dietary Manager (CDM). According to the internal thermometer located in the walk-in freezer, the internal temperature of the freezer was 20 degrees Fahrenheit (F). A five-gallon container of strawberry ice cream stored on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide treatment and care to residents in accordance with professional standards of practice for four of 19 sampled residents (Resident 17, 50, 21, and 23) when: 1. Resident 17 had continuous oxygen (02) administered with no Medical Doctor (MD) order. 2. Resident 50 did not have medication administered as directed by MD order. 3. Resident 50 did not have 02 tubing changed weekly and labeled per resident centered care plan, nor professional standard of practice. 4. Resident 21's treatment was not completed as directed by MD order. 5. Resident 23 did not have 02 tubing labeled and dated per resident centered care plan, nor professional standard of practice. These failures of not following or obtaining MD orders, nor adhering to medical professional standards of practice had the potential to result in profound physical health complications, increased mental health problems, and general decline. Findings: During a review of the facility's…

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

Based on observation, interview, and document review, the facility failed to provide 80 square feet per resident per room in 12 of 22 resident rooms, as required by regulation (Rooms 1, 2, 3, 4, 5, 17, 18, 19, 20, 21, 22, and 23). This failure had the potential to result in inadequate space for care and services provided as well as potential to negatively affect resident physical and emotional comfort and feelings of overall well-being. Findings: During the entrance conference on 6/16/25 at 10:00 am, a previous copy of the waiver for reduced bedroom sizes granted to the facility by the Centers for Medicare & Medicaid services (CMS) was discussed and reviewed with the Administrator (Admin). There has been no physical expansion for rooms since the last survey. During a review of resident census information provided 6/16/25, titled, Resident List Report, and a bed roster list, indicated rooms 1, 2, 3, 4, 5, 17, 18, 19, 20, 21 and 23 had determined capacity with beds present to hold three residents per room. During concurrent observation and interview throughout the survey, 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.

Based on observation, interview, and record review, the facility failed to provide Physical Therapy (PT) in a timely manner to meet the needs of one of 19 sampled residents (Resident 31) when needed therapy services were delayed due to an insurance transfer from another facility. This failure caused Resident 31 to feel angry, sad, and had the potential for a functional decline. Findings: The facility's policy revised 2025, titled, Resident Rights, indicated all residents will be treated equally regardless of age, sex, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sexual orientation, or gender identity or expression. The facility will ensure that all direct care staff and individual staff members, including contractors and volunteers, are educated on the rights of the residents and responsibility of the facility to properly care for its residents. The facility's policy revised 2024, titled, Therapy Evaluation, indicated the licensed therapist will perform an initial resident evaluation upon physician referral and any re-evaluation where…

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

Based on interview, and record review, the facility failed to ensure one of 19 sampled residents (Resident 21) was treated with dignity and respect when Registered Nurse (RN) G was rude during direct resident care. This failure had the potential to result in emotional stress, embarrassment, feelings of neglect, increased anxiety, and the potential for negative clinical outcomes. Findings: The facility's policy revised 8/2024, titled, Promoting/Maintaining Resident Dignity, indicated it is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. The facility's policy revised 2025, titled, Resident Rights, indicated all residents will be treated equally regardless of age, sex, ethnicity, religion, culture, language, physical or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of two residents sampled for Abuse (Resident 7), was free from verbal abuse when Certified Nurse Assistant (CNA) I verbally abused Resident 7. This failure had the potential to negatively impact Resident 7's sense of security, emotional, and psychological well-being. Findings: During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, and Exploitation, no date, the P&P indicated, Abuse is defined as, the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse, Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It…

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 that the Interdisciplinary Team (IDT, the facility managers who meet to discuss the care needs of the residents) developed care plans for one of nineteen sampled residents (Resident 23), when there was no care plan developed for pain management or oxygen use for Resident 23. This failure had the potential for staff to not be fully informed on Resident 23's needs regarding pain control and respiratory care. Findings: During a review of the facility policy titled, Comprehensive Care Plans, undated, indicated, that the facility will develop and implement a comprehensive person-centered care plan for each resident. The care plan will be revised by the interdisciplinary team after each comprehensive and quarterly Minimum Data Set (MDS, an assessment tool) assessment. During a review of record titled, admission Record, with an admission date of 5/29/25, indicated that Resident 23 was admitted with diagnoses that included chronic pain and syncope (fainting spells). During a review of Resident 23's Mimimum…

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 patient -center care plan for one of two sampled residents (Resident 1) with dementia (loss of memory, language, and problem-solving) when: 1. Resident 1 became physically aggressive when given a shower and Certified Nursing Assistant (CNA) A did not follow interventions to leave and return 5-10 minutes later and try again. 2. Interventions were not developed to address Resident 1's preference of taking showers in the afternoon. These failure contributed to Resident 1 becoming combative, and CNA A grabbing onto Resident 1's wrist which became red, swollen and tender. Findings: A review of the facility's policy titled Comprehensive Care Plans (undated) indicated that it was the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident 3. The comprehensive care plan will describe, at a minimum, the following f. Resident specific interventions 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 interview, and record review, the facility failed to ensure a care plan for one of three sampled residents (Resident 2) was revised and updated to reflect current individual needs for a change in condition after a hospitalization to include comfort care (end of life care wishes) with new pain medications. This failure resulted in Resident 2's individualized care needs to go unrecognized, and the potential for a further decline in Resident 2's physical, mental, and psychological status. Findings: During a review of a policy revised 8/2024, titled, Care Plan Revisions Upon Status Change, indicated the purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. The care plan will be updated with the new or modified interventions. Staff involved in the care of the resident will report resident response…

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 skin assessment was completed upon re-admission to the facility for one of two sampled residents, (Resident 2). This failure had the potential for a negative clinical outcome, re-hospitalization, and Resident 2 had specific skin treatment needs that were not identified in a timely manner. Findings: The facility's policy dated 2/2023, titled, admission Orders, indicated the orders should allow facility staff to provide essential care to the resident consistent with the resident's mental and physical status on admission. This facility's policy also indicated the admission orders should provide information to maintain or improve the resident's functional abilities until staff can conduct a comprehensive assessment and develop an interdisciplinary care plan. The facility's policy not dated titled, Charting Guidelines, indicated new admissions requirement in Point Click Care (PCC) included functional abilities and goals completed every shift for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to thoroughly investigate an allegation of abuse involving two residents (Residents 1 and 2) and provide the California Department of Public Health (CDPH) with the 5-day investigation results. This failure had the potential for abuse allegations to go uninvestigated and placed residents living at the facility at risk for harm. Findings: A review of the facility ' s undated policy and procedure (P&P) titled, Abuse, Neglect, and Exploitation, indicated, the facility would identify and interview all people that were involved in allegations of abuse to include: alleged victims, alleged perpetrators, witnesses, and any one with information regarding the allegations. The P&P indicated, The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies. A review of the Report of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that only staff with a verified license were assigned to care for patients when one staff member was assigned nursing duties before the facility verified she had obtained a nursing license. This had the potential to effect the safety and quality of care for all residents of the facility. Findings: During an interview on [DATE] at 10:15 am, with the Director of Nurses (DON) she stated that Staff A (SA) had been a Certified Nurse Assistant (CNA) for 8 years at the facility. SA had furthered her education, graduating from school to become a Licensed Vocational Nurse in 12/2023. On [DATE] SA reported to the facility that she passed her licensing exam to become a Licensed Vocational Nurse. During a recent review it was noted SA ' s employee file did not include online verification of SA ' s nursing license. DON spoke to SA, who stated she had passed her test and submitted the documentation to the Director of Staff Development (DSD). When DON followed…

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 sufficient nursing staff for the first and second quarters of the year of 2024. This failure had the potential to result in the facility to not provide necessary care and services to meet the need of the resident, and maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Findings: During a review of the facility mandatory submission of staffing information based on payroll data - the Payroll-Based Journal (PBJ- was created by The Centers for Medicare & Medicaid Services (CMS) as a method to collect auditable and verifiable staffing data from nursing facilities. PBJ reporting is a requirement of all long-term care facilities to promote accountability and consistency), indicated: 1. In the first quarter of 2024, dated 10/1/23 to 12/31/23, the facility failed to have Licensed Nursing Coverage 24 hours/Day on 10/28/23, 11/4/23, 11/5/23, 11/11/23, 11/16/23, 11/23/23, 11/25/23, 11/26/23, 12/9/23, and 12/25/23. 2. In the second quarter of 2024, dated 1/1/24 to 3/31/24, 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 interview and record review, the facility failed to ensure an Registered Nurse (RN) was on duty at least eight consecutive hours a day, seven days a week for the first and second quarters of the year of 2024. This failure had the potential to result in the facility to not provide care and services to meet the residents' needs for nursing care in a manner and in an environment which promoted each resident's physical, mental, and psychosocial well-being, thus enhancing their quality of life. Findings: During a review of the facility mandatory submission of staffing information based on payroll data - the Payroll-Based Journal (PBJ- was created by The Centers for Medicare & Medicaid Services (CMS) as a method to collect auditable and verifiable staffing data from nursing facilities. PBJ reporting is a requirement of all long-term care facilities to promote accountability and consistency), indicated: 1. In the first quarter of 2024, dated 10/1/23 to 12/31/23, the facility failed to have RN hours on 10/21, 10/22, 10/28, 10/29; 11/04, 11/5, 11/11, 11/12, 11/15, 11/16, 11/17,…

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, record review, the facility failed to ensure the kitchen had sufficient and competent dietary staff in the position to perform their related duties when: 1. Eight out of 10 kitchen staff did not have the required competencies and training to peform their job duty requirements. 2. Two of 10 kitchen staff were unable to verbalize and demonstrate how to test the sanitizing solution and how to set up an emergency 3-compartment sink (wash by hand) according to the manufacturer guidelines. 3. One of 10 kitchen staff did not know the correct temperature of walk-in freezer and did not report the issues to adminstrative staff. These failures had the potential to result in foodborne illnesses from cross contamination or the growth of microorganisms for the 49 residents eating food prepared in the facility. Findings: 1. A review of a Dietary Manager job description dated 2022, indicated the minimum requirements include one of the following certifications as a dietary manager, food service manager national certification for food service management from national…

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, prepare, distribute, and serve food in a sanitary manner in accordance with professional standards for food service safety when: 1. Freezer temperatures were not maintained within range. 2. Food was improperly dated in refrigerator and dry storage. 3. Two of 10 kitchen staff were unable to verbalize and demonstrate how to test the sanitizing solution and how to set up an emergency 3-compartment sink (wash by hand) according to the manufacturer guidelines. 4. Flies and other pests throughout the kitchen during cooking and plating food (tray-line). 5. Dirty scoop, mixing bowl and garbage can lid. 6. Dietary staff did not wash hands before handling food in kitchen. 7. Non dietary staff service vendor entered tray-line cooking area multiple times during meal preparation without hair and face net. These failures had the potential to result in foodborne illnesses from cross contamination or the growth of microorganisms for the 49 residents eating food prepared in the facility. Findings: 1. A review of a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility's Administrator (ADMIN) failed to ensure effective oversight and necessary resources to ensure resident care services were met to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident when: 1. The ADMIN failed to ensure a full time Registered Dietician (RD) or a Certified Dietary Manager (CDM) to provide direct oversight of dietary staff to deliver safe and sanitary food service for 49 of 49 residents. a. Dietary staff did not follow safe and sanitary food service practices. Refer to F 802 and F 812. b. RD, Unqualified Dietary Manager (UDM), and CDM did not ensure all dietary staff had required state and federal competencies to work in the kitchen upon hire. Refer to F 802 c. RD did not ensure all identified issues in the kitchen/sanitation audits were acted upon and resolved. Refer to F 812 This resulted in an Immediate Jeopardy (IJ - a situation where a provider's noncompliance with requirements has, or…

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

Based on interview and record review, the facility's Governing Body (GB, legally responsible for establishing and implementing facility policies) failed to effectively manage the facility when: 1. The GB did not ensure adequate oversight and monitoring of the dietary department. Refer to F 801, F812. 2. The GB failed to ensure and effective Quality Assessment and Assurance Program to identify, implement corrective actions and evaluate their effectiveness. This resulted in an Immediate Jeopardy (IJ - a situation where a provider's noncompliance with requirements has, or could, result in serious harm, injury, impairment, or death to a resident) for failure to provide qualified oversight to perform daily kitchen inspections, provide feedback to staff, ensure kitchen staff is competent in performing their job duties effectively. Refer to F 801. Findings: During a review of the facility's undated policy titled, Governing Body, indicated: - The facility will have a governing body, or designated persons functioning as a governing body, that is legally responsible for establishing 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 have an effective Quality Assurance Performance Improvement (QAPI) committee when they did not identify nor correct facility issues to ensure care and services met resident needs when: 1. There was no full time Registered Dietician (RD) or a Certified Dietary Manager (CDM) to provide direct oversight of dietary staff to deliver safe and sanitary food service for 49 of 49 residents. This resulted in an Immediate Jeopardy (IJ - a situation where a provider's noncompliance with requirements has, or could, result in serious harm, injury, impairment, or death to a resident) for failure to provide qualified oversight to perform daily kitchen inspections, provide feedback to staff, ensure kitchen staff is competent in performing their job duties effectively. Refer to F 801. 2. Dietary services did not follow national standards and guidelines for kitchen cleanliness, and the safety of the food storage. Refer to F 812. 3. The staff did not identify insidious weight loss (gradual, unintended, progressive weight loss over time), 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 have an effective Quality Assessment and Assurance (QAA) program, when the QAA committee did not adequately identify, address, implement or monitor the effectiveness of implemented plans of action to correct deficiencies when: 1. There was no full time Registered Dietician (RD) or a Certified Dietary Manager (CDM) to provide direct oversight of dietary staff to deliver safe and sanitary food service for 49 of 49 residents. This resulted in an Immediate Jeopardy (IJ - a situation where a provider's noncompliance with requirements has, or could, result in serious harm, injury, impairment, or death to a resident) for failure to provide qualified oversight to perform daily kitchen inspections, provide feedback to staff, ensure kitchen staff is competent in performing their job duties effectively. Refer to F 801. 2. Dietary services did not follow national standards and guidelines for kitchen cleanliness, and the safety of the food storage. Refer to F 812. 3. The staff did not identify insidious weight loss (gradual,…

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 essential facility equipment was maintained when: 1. Communication call light system was working for two rooms. This failure had the potential for residents with non-working call light systems to be at risk for accidents and their care needs not being met. 2. Walk-in freezer was not keeping food at the required 0 or below degrees Fahrenheit (F). 3. Dishwasher in the kitchen was not working. The dietary department equipment not in working order which had the potential for all residents to be at risk for food borne illness. Findings: A review of the facility's policy titled Call Lights: Accessibility and Timely Response (undated), indicated The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow resident to call for assistance. During a facility tour on 8/7/24 from 2:50 pm to 3:50 pm, with the Plant Operations Supervisor (POS), the call light system was observed. Residents in rooms 19 A and 11 B…

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 they maintained an effective pest control program when flies and other pests were observed throughout the building. This resulted in residents to experience flies landing on them during meals and did not honor their right to have a home environment free from pests. Findings: A review of a facility policy titled Pest Control Program dated 2024, indicated an effective pest control program was defined as measures to remove and contain any common household pests (e.g. flies, ants, and roaches). Facility will utilize a variety of methods in controlling the pests. These will involve indoor and outdoor methods. A review of a Registered Dietician (RD) inspection of the kitchen on 5/1/24 at 8:29 pm, emailed to Administrator (ADMIN) and Governing Body (GB), indicated findings for the audit: -.gap under screen door in kitchen, this door will be an issue with flies as weather heats up. A review of sanitation findings on 5/30/24 at 8:41 am,…

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 reasonable accommodation(s) of resident needs and preferences for three of 33 residents (Resident 45, 38 and 35) in room [ROOM NUMBER] with less than 80 square feet per resident. This resulted in Resident 35 not being able to achieve independent functioning, dignity, and put all residents in room [ROOM NUMBER] at risk for accidents and hazards. Refer to F 912. Findings: A review of a facility policy titled Accommodation of Needs revised March 2021, indicated our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity, and well-being. Moving furniture or large items in rooms and common areas that may obstruct the path of a resident using a walker, arranging furniture as the resident requests, providing the arrangement is safe, his or her roommate agrees, and space allows. In order to accommodate individual needs and preferences,…

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 that the Interdisciplinary Team (IDT, the facility managers who meet to discuss the care needs of the residents) reviewed and revised the care plan for three of seven (Resident 8, 15, and 52)) sampled residents when: 1. Resident 15 had two falls without injury and the care plan was not revised or reviewed which resulted in Resident 15 having another fall with injury. Refer to F689. 2. Resident 8 had two Hoyer lift (a mechanical device use to lift an individual from a bed or wheelchair) incidents and the care plan was not revised or reviewed timely. 3. Resident 52 who had multiple fall history, the care plan was not revised or reviewed timely. These failures had the potential for staff to not be fully informed of the residents' health status to determine the need for further assessment and intervention. Findings: A review of the facility's policy titled, Care Plans, Comprehensive Person-Centered dated March 2022, indicated 11. Assessments 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's nursing staff failed to assess and reevaluate the continued need for a suprapubic urinary catheter (a hollow flexible tube inserted through a cut in the abdomen that is used to drain urine from the bladder into a bag) for one of four sampled residents (Resident 12). The delay in identifying a change in condition resulted in emergent hospitalization, pain, and urinary tract infection (UTI - bacterial infection in urinary system). Findings: A review of a policy titled Change in a Resident's Condition or Status, revised February 2021, the nurse will notify the resident's attending physician if a significant change in the resident's physical/emotional/mental condition; a significant change of condition is a major decline that will not normally resolve itself without intervention and requires interdisciplinary review and/or revision of care plan. Review of document Pain - Clinical Protocol 2001 MED-PASS, Inc. indicated The nursing staff will assess each individual…

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 social services met the needs for four of 12 sample residents (Resident 6, 8, 12, and 303) when: 1. Weekly telehealth psychic assessment and evaluation was ordered for Resident 6. This had the potential that mental health resources were overused and wasted, and unnecessary medical treatment was provided to Resident 6 who did not exhibit any behavior issue. 2. Quarterly care conference was not arranged for Residents 8. This failure resulted in Residents 8 missing the opportunities to discuss and express the concerns related to the care Resident 8 had received. 3. Discharge Care Planning was not developed for Resident 303. This had the potential for Resident 303 to not be emotionally prepared for discharge. 4. Urology consult was not arranged for Resident 12. This had potential for further infections and complications related suprapubic catheter (a hollow flexible tube that is used to drain urine from the bladder through a cut 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 observation, interview, and record review, the facility failed to store drugs under proper temperature controls and failed to label drugs in accordance with professional standards when: 1. The medication room (where medications were stored) had temperatures that exceeded manufacturer's recommendations. This failure had the potential to compromise the medications stored in the medication room. 2. One of nine resident's (Resident 302), sampled for medication administration, had physician's instructions on the Medication Administration Record (MAR) for potassium chloride to be given with a full glass of water and the pharmacy label instructions for administration of the medication to be given with food. This failure had the potential for Resident 302 to experience abdominal discomfort if potassium chloride was not given as indicated by the manufacture instructions. Findings: 1. A review of the facility's policy titled, Medication Storage (undated), indicated It is the policy of this facility to ensure all…

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 document review, the facility did not provide 80 square feet per resident, as required by regulation, in 12 resident rooms (Rooms 1, 2, 3, 4, 5, 17, 18, 19, 20, 21, 22, and 23). This had the potential to result in inadequate space for care or services and impact a residents' right to an environment that meets the unique needs and preferences and prevents them from achieving independent functioning, dignity, and well-being. Refer to F558. Findings: During a review of a former recertifcation survey, a room waiver for the reduced bedroom sizes less than 80 sqaure feet was requested by the facility and granted by the Centers for Medicare & Medicaid services. There was no expansion since the last survey. A copy of the resident roster dated 8/6/24, indicated rooms 1, 2, 4, 5, 17, 18, 19, 20, 21, 22, and 23 had three residents per room. room [ROOM NUMBER] had no residents. During a concurrent observation and interview on 8/07/24 at 3:35 pm in room [ROOM NUMBER], Resident 35 stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two Quarterly Minimum Data Set Set (MDS, a standardized assessment of an adult's functional, medical, psychosocial, and cognitive status) assessments were accurate for one of seven (Resident 15) residents sampled for falls, when the fall section of the MDS did not identify Resident 15's two falls. This failure resulted in Resident 15 having multiple falls due to having an inaccurate reflection of what care was needed to prevent falls. Findings: A review of the facility's policy titled, MDS 3.0 Completion (undated), indicated Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan. According to federal regulations the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity, using the RAI (Resident Assessment Instrument) specified by the State. A record review of Resident 15's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete baseline care plans (initial goals with interventions based on admission orders and assessments, which provide instructions for immediate care of the resident) for two of seven residents (Resident 15 and 303) when Resident 15 and Resident 303 did not have a baseline care plan developed for being at risk for falls in the first 48 hours of admission to the facility. This failure resulted in Resident 15 and Resident 303 not having appropriate care needed to prevent falls. Findings: A review of the facility's policy titled, Baseline Care Plan (undated), the policy indicated The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. 1. The baseline care plan will: a. Be developed within 48 hours of a resident's admission. 2. The admitting nurse, or supervision nurse on duty, shall…

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 comprehensive care plans for two of seven sampled Residents when: 1. Resident 15 was at risk for falls and there was no comprehensive Fall Care Plan developed with interventions to prevent Resident 15 from falls. This failure resulted in three falls for Resident 15. 2.a. Resident 303 was at risk for falls and there was no comprehensive Fall Care Plan developed to prevent 303 from falls. b. Resident 303 was planning on going home but there was no Discharge Care Plan developed. These failures put Resident 303 at risk for falls and the feeling of being uniformed of her discharge plans. Refer to F689 Findings: A review of the facility's policy titled, Comprehensive Care Plans revised date of October 2022, indicated It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical,…

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 two of seven sampled residents (Resident 15 and 303) who were evaluated for their risk for falls, reevaluated after falls, or had care planned interventions to prevent falls and/or further falls when: 1. Resident 15 had inaccurate and absent Fall Risk Evaluations, (an assessment that checks a resident's risk of falling by assessing clinical conditions including mental status, history of falls, vision, walking and balance, blood pressure, and medications that would increase a risk of falling.) and did not have Fall Care Plans developed with interventions to prevent falls. 2. Resident 303 had an inaccurate Fall Risk Evaluation and did not have a Fall Care Plan developed with interventions. These failures resulted in continued falls for Resident 15 and put Resident 303 and all residents, who were at risk for falls, to be at risk for further falls and injuries. Findings: A review of the facility's policy titled, Fall Prevention…

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 pain medication was administered as per physician order for one of nine residents (Resident 303), sampled for medication administration, when gabapentin (a pain medication) was not administered as prescribed by the physician. This failure placed Resident 303 at risk for poor pain control and a decrease in health and well-being. Findings: A review of the facility's policy titled, Medication Administration (undated), indicated Medications are administered by licensed nurses . as ordered by the physician and in accordance with professional standards of practice A record review of Resident 303's admission Record (undated), indicated Resident 303 was originally admitted on [DATE] and then readmitted on [DATE] after a brief hospital stay. Resident 303's diagnoses included fracture (broken bone) of right leg, lung disease, muscle weakness, anxiety disorder, dependence on oxygen, and depression. During a concurrent observation 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 the residents had a safe, comfortable, and homelike environment and implement their policy titled, Loss or Heating or Cooling (undated) when: 1. Six of 16 residents (Resident 1, 2, 3, 4, 5, and 6) complained of their room and the dining room being too hot for them. 2. The facility did not take immediate actions to fix the air-conditioner (AC) as per their policy, when one of two ACs was not working on June 3, 2024. 3. The facility did not report the interruption of the essential services (air conditioning) to the California Department of Health (CDPH) as per their policy titled, Unusual Occurrence Reporting (undated). These failures had the potential for residents to be susceptible to dehydration (lack of total body water), risk of hyperthermia (overheating) and the actual feelings of being hot, have difficulty breathing, eating, sleeping and feeling uncomfortable. Findings: A review of the facility's policy titled, Resident Rights…

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 care equipment was maintained in a safe operating condition when a large metal meal tray cart (tray cart, large metal cart on wheels that was used to transport resident meal trays) fell over when the housekeeper (HK) moved the tray cart out of her way. This failure had the potential to cause physical and psychosocial injury to residents. Findings: A review of the facility's undated policy and procedure (P&P) titled, Physical Environment: Space and Equipment, indicated, Inspection of resident care equipment will be completed routinely and as needed to maintain and ensure safe operating conditions according to manufacturer's recommendations. During an observation on 6/21/24 at 8:44 am, residents were observed sitting in the lobby and near the nurse's station upon entry to the facility. A tray cart was observed falling over and landing approximately 7 feet away from a resident who jumped and yelled, Oh my God that scared me, that scare me. During a concurrent observation and interview on 6/21/24…

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 dignity and privacy were maintained for two residents (Resident 1 and Resident 3) when a psychiatric tele health (appointment with a health care provider conducted remotely on a video screen), visits were conducted in a public location. This had the potential for other residents, staff, and visitors to overhear protected and private information. Findings: Resident 3 was readmitted to the facility on [DATE] with diagnoses that included aphasia (difficulty communicating) and hemiplegia (one sided inability to control body movements) both related to a stroke. During an observation on [DATE] at 10:18 am, Resident 3 was observed to be seated in his wheelchair in the central hallway. This location is across from the nurse ' s station, facing the lobby. Two individuals wearing black scrubs approached Resident 3 while pushing a bedside tray with a laptop (computer) on it. They positioned the laptop screen to face Resident 3 then…

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 maintain a clean, safe and homelike environment for two of four non-smoking residents (Resident 4 and 5), sampled for the effects of smoking in the facility when; 1. Resident 4 had to keep her curtains and window closed in her room because the dedicated smoking section was right outside her window and residents would peer into her room while smoking. 2. Resident 5 had to keep her window closed in her room because the dedicated smoking section was right outside her window and when smoke came in her room, she would experience breathing issues. This failure had the potential to negatively affect the quality of life for Resident 4 and 5. Findings: A review of the facility ' s undated policy titled, Resident Rights indicated, The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. During an observation and interview with the Activity…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the safety for three of nine residents (Resident 1, 2, and 3), sampled for safe smoking, when: 1. Resident 1's Safety Smoking Evaluation identified Resident 1 to have unsafe smoking behaviors but determined him to be an independent smoker (safe to smoke unsupervised) and was observed to have unsafe smoking behaviors. Residents 1 was observed smoking without using a smoking apron (a covering to protect the resident from dropping hot ashes on their clothes), an ashtray, and was smoking outside in an undesignated smoking section (a designated smoking area was where smokers are instructed to smoke and was equipped with a fire extinguisher, smoking blanket, and an ash tray), which did not have a fire extinguisher, smoking blanket, or an ash tray. 2. Resident 2's Safety Smoking Evaluation determined him to be an independent smoker but was observed to have unsafe smoking behaviors. Residents 2 was observed smoking without using a smoking…

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

Based on interview and record review the facility failed ensure one of two sampled residents (Resident 1), reviewed for physician orders for a Psychologist (a person who treats mental, emotional and behavioral disorders) evaluation, received appropriate treatment and services. This failure had the potential to cause a deterioration of Resident 1's mental and psychosocial well-being. Findings. A review of the facility's policy titled Provision of Physician Ordered Services dated February 2023, indicated Qualified nursing personnel will submit timely requests for physician ordered services (laboratory, radiology, consultations), to the appropriate entity. A review of the facility's policy titled Social Services dated February 2023, indicated The facility, regardless of size, will provide medically-related social services to each resident to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The social worker, or social service designee, will pursue the provision of any identified need or medically-related social services of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to timely administer routine medications to meet the needs of the residents, when one of three residents sampled for timely medication administration (Resident 1) had multiple incidents of routine pain medications being administered from two to six hours late, after the time the medications were ordered to be administered. This failure had the potential to cause Resident 1 to experience increased incidents of general uncontrolled pain issues and negatively impact their physical and emotional health and well-being. Findings: During a review of the facility's policy and procedure titled, Medication Administration , revised February 2023, indicated, Medications are administered by licensed nurses .as ordered by the physician and in accordance with professional standards of practice .Administer within 60 minutes prior to or after scheduled time. During an interview on 3/28/24 at 11:45 am, with Resident 1, who stated, on 3/19/24 he had to wait for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to accommodate for one of four sampled residents (Resident 2), who were reviewed for their ability to use the call system (The system that allows residents to notify the staff if they need or want something.), when Resident 2 was paralyzed from the neck down and had a call light that required the use of her hands to operate it. This failure caused Resident 2 to have to yell for help while in her room and made her feel like she was a prisoner. Findings: A review of the facility ' s undated policy titled, Resident Rights indicated 4. The resident has a right to be treated with respect and dignity, including: c. The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences A review of the facility ' s policy titled, Call Lights: Accessibility and Timely Response dated February 2023, indicated, Each resident will be evaluated for unique needs and preferences to determine any special…

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 use the services of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week. This failed action had the potential for residents not to be assessed and provided RN services when required. Findings: On 4/16/24 the California Department of Public Heath (CDPH) received notification that the facility failed to have the required RN hours since 4/1/24. On 4/19/23 at 12:25 pm, RN hours per timecards were requested from the facility Administrator (Admin) to from 4/1 to 4/19/24. A review of the RN hours provided on 4/19/23 indicated: On 4/1/24, RN A worked 2.58 hours. On 4/2/24, RN A worked 2.10 hours. On 4/3/24, RN A worked 0.70 hours. On 4/9/24, RN A worked 0.57 hours. There were no hours documented for 4/10, 4/11, 4/15, 4/16, 4/17, 4/18, and 4/19/24 as requested (Total of eleven days). On 4/23/24 at 11:30 am the RN Director of Nurses (RN/DON) was interviewed while reviewing the provided hours above. RN/DON stated she started working at the facility on 4/4/24 but her hours are not recorded as she is paid a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two out of three sampled residents (Residents 1 and 2) were provided with help to set up their supplies to brush their own teeth when: 1. Resident 1's toothpaste and toothbrush was on her nightstand and she could not reach them. 2. Resident 2's mouthwash and a cup to rinse her mouth were not set up for her to independently use, when she was paralyzed (not able to move), on her right side. This had the potential for Residents 1 and 2 to develop cavities, mouth pain and gum disease and could cause a decline in their ability to perform oral hygiene with minimal staff assistance, and had the potential for all residents who needed help with oral care to have a decline in their oral health status. Findings: 1. A review of the facility ' s undated policy and procedure (P&P) titled, Activities of Daily Living (ADLs), indicated A resident who is unable to carry out activities of daily living will receive the necessary services to maintain…

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 two out of three sampled Certified Nurse Assistants (CNAs) demonstrated competencies (Centers for Medicare and Medicaid defined competency as a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully), when the Director of Staff Development (DSD) did not evaluate CNA A and CNA B's competencies and skill sets prior to working with residents who lived at the facility. This had the potential to negatively impact resident's physical, mental, and psychosocial well-being. Findings: A review of the facility's undated policy and procedure (P&P) titled, Competency Evaluation, indicated, It is the policy of this facility to evaluate each employee to assure appropriate competencies and skills for performing his or her job and to meet the needs of the facility residents. The P&P indicated the facility evaluated staff's competency during training and orientation (providing a new employee information about the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to that two of three sampled residents (Resident 1 and Resident 2), had accurate and/or complete Activities of Daily Living (ADLs- dressing, grooming, bathing, toileting and hygiene), documentation in their medical record when, both resident's ADL records contained incomplete documentation as to whether or not the residents had received oral care and incontinent (no control over bowel and bladder), care. This failure had the potential for an inaccurate representation of Resident 1 and 2's current status and for changes to go unrecognized, which could negatively impact their continuity of care and health status. Findings: A review of the facility ' s policy and procedure (P&P) titled, Charting and Documentation, revised 7/1/17, indicated, treatment and services provided to the resident would be documented. The P&P indicated, documentation would include the date and time the procedure/treatment was provided. A review of Resident 1 ' s undated…

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 obtain medication for one of two sampled residents (Resident 2) when medication prescribed by physician was not available for administration. This failure had the potential to negatively affect Resident 2 ' s health due to multiple sclerosis (MS-a disease of the brain and spinal cord causing weakness, numbness, partial or complete loss of vision, fatigue, memory, mood and cognitive problems). Findings: During a review of hospital document titled, History and Physical dated 12/30/2024 at 7:03 pm, by Medical Director (MD) 1 indicated Resident 2 was admitted with a diagnosis of MS, pneumonia (an infection of the lungs), asthma (a disease of the lungs causing wheezing, shortness of breath, coughing and chest tightness), and depression (a serious mental health disorder causing decreased interest in pleasurable activities, low or depressed mood, feelings of guilt or worthlessness and problems eating, sleeping, concentrating and working). Resident 2's home medications included dimethyl fumarate (Tecfidera (brand…

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 that one of two sampled residents (Resident 1), received treatment and care in accordance with professional standards of practice when Resident 1 experienced symptoms of a urinary tract infection (UTI-an infection of the bladder) and no laboratory test were ordered for eight days. This deficient practice had the potential for Resident 1 to go without laboratory monitoring to detect signs of infection and not to receive appropriate care and treatment. Findings: During a review of facility document titled, admission Record dated 1/1/2024, Resident 1 was admitted with diagnoses of surgical aftercare following surgery of the nervous system (needing care after surgery), diabetes, weakness and urinary tract infection. During a review of facility document titled, Progress Notes dated 1/12/2024 at 12:14 pm, Licensed Vocational Nurse (LVN) 4 documented that Resident 1 reported to her that she was experiencing pain and burning during urination, increased frequency of urination and urgency. LVN 4 documented 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 protect the residnts' right to be free from deprevation of goods and services for three out of three sampled residents (Resident 1, 3, and 4) when: 1a. The facility had no documented evidence for providing wound care as ordered by the physician for Resident 1. (Refer to F684) 1b. The facility had no documented evidence for providing wound care as ordered by the physician for Resident 3. (Refer to F684) 1c. The facility had no documented evidence for providing wound care as ordered by the physician for Resident 4. (Refer to F684) 2a. The facility ran out of wound care supplies for Resident 1, that were necessary to provide care and physician ordered wound care. (Refer to F684) 2b. The facility ran out of wound care supplies for Resident 3, that were necessary to provide care and physician ordered wound care. (Refer to F684) 3a. Resident 1 had a 17-day delay in ordered wound care physician services. (Refer to F684) 3b. Resident 3 had 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 identify or provide needed wound care and services to three out of three sampled residents (Residents 1, 3, and 4) when: 1. The facility failed to ensure Licensed Nurses (LN) provided Resident 1 with wound assessments (an exam that described the condition of a wound and measurements) that accurately reflected Resident 1's wound condition upon admission to the facility, did not provide Resident 1 with physician ordered wound consult (a doctor that specialized in wound care to exam the wound), did not document physician ordered wound care treatment (care that was ordered to treat the wound), and did not have required wound care supplies. 2. The facility failed to ensure Resident 3 was provided with physician ordered wound consult, LN's did not document physician ordered wound care treatment, and did not have required wound care supplies. 3. The facility failed to ensure LN's document physician ordered wound care treatment for Resident 4.…

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

Based on interview and record review the facility failed to report an outbreak of COVID-19 to the California Department of Public Health (CDPH, works to protect the public's health) when six residents and four staff members tested positive for COVID-19. This failure had the potential for the further spread of COVID-19 to other residents. Findings: A review of the All Facilities Letter (AFL, a letter that contained information regarding changes in requirements to healthcare), dated 1/18/23, indicated This AFL reminds licensed health facilities of requirements to report outbreaks and unusual infectious disease occurrences to their local health department (LHD) and Licensing and Certification District Office . The AFL indicated COVID-19 outbreaks were reportable to CDPH. A review of the facility's policy and procedures (P&P) titled, Outbreak of Communicable Diseases, revised 9/1/22, indicated, The administrator is responsible for .communicating data about reportable diseases to the public health department. During a review of the line listing (a list of all residents and staff, 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.

Based on observation, interview, and record review, Licensed Nurse (LN) B failed to explain what nursing services were being provided to one out of two sampled residents (Resident 2) when LN B handed Resident 2 a cup full of medication without explaining what medication was being provided. This failure had the potential to not allow Resident 2 the right to be informed or make an informed decision regarding care and services received by the facility. Findings: A review of the facility's policy and procedure (P&P) titled Resident Rights Guidelines for All Nursing Procedures, revised 10/1/10, indicated, facility staff would Explain the procedure to the resident. During a concurrent observation and medication label review on 3/6/24 at 8:08 am, on Wing 1, Resident 2 was sitting in a wheelchair next to LN B's medication cart (cart on wheels that contained resident medication). LN B was observed preparing Resident 2's medication as followes: Metformin (medication that treated diabetes) 500 milligrams (mg, unit of measure) tab take one tablet by mouth twice daily, adult low dose chewable…

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 accommodate the needs of one out of three sampled residents (Resident 1) in a timely manner when Resident 1 requested the use of bedrails (metal or plastic bars attached to side of bed) to promote mobility and independence (the ability to turn, reposition, or sit up without the assistance of staff). This failure had the potential for an inability to maintain independence or achieve independent functioning and effect resident well-being. Findings: During a review of the facility ' s policy and procedure (P&P) titled, Activities of Daily Living, revised 3/1/18, indicated Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). The P&P indicated, Interventions to improve or minimize a resident ' s functional abilities will be in accordance with the residents assessed needs, preferences, stated goals, and recognized standards of practice.…

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 privacy curtain track (a metal rail attached to the ceiling that held a moveable curtain that provided residents with privacy) in one out of three observed resident rooms (Resident 1), was in good repair when an approximated two-foot-long section was detached from the ceiling. This had the potential for the privacy curtain to not work properly or to detach further from the ceiling and fall onto Resident 1's bed. Findings: During a review of the facility's policy and procedure (P&P) titled, Homelike Environment, revised 2/1/21, indicated, Residents are provided with a safe, clean, comfortable and homelike environment During a concurrent observation and interview on 3/5/24 at 2:38 pm, located in Resident 1's room, with Maintenance Director (MD) and Resident 1, the privacy curtain, located nearest to the door of the room was observed. MD stated, approximately two feet of privacy curtain track was detached from the ceiling, and at the center of the approximated two-foot section, the track made a V like…

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, Licensed Nurse (LN) A (an MDS nurse) inaccuratley coded the Minimum Data Set (MDS, a comprehensive assessment tool that helped identify resident care problems) for one out of three sampled residents (Resident 1) when: 1. LN A inaccurately coded the MDS for Section H- Bowel and Bladder for Resident 1, indicating that Resident 1 was incontenent (not having control over bowel and bladder) when Resident 1 was continent (having control over bowel and bladder). 2. LN A inaccurately coded the MDS for Section M- Skin Conditions For Resident 1, indicating that Resident 1 did not have wounds when Resident 1 was admitted with two wounds. This failure had the potential for a decline in Resident 1's wound and bowel and bladder status. Findings: 1. During a review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User ' s Manual, Version 1.17.1 (RAI, a document that provided clear guidance about how to use the RAI correctly and effectively to provide…

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 out of three sampled residents (Resident 1) received wound care treatment and services necessary to avoid a facility aquired pressure ulcer that was not present upon admission. This failure contributed to the development of a Stage 2 pressure injury (CMS defined a Stage 2 Pressure injury as: partial thickness loss of skin presenting as a shallow ulcer with red or pink wound bed, without slough or bruising) to the coccyx (tail bone area). Findings: A review of the facility's undated policy and procedure (P&P) titled, Pressure Injury Prevention Guidelines, indicated Individualized interventions will address specific factors identified in the resident's risk assessment, skin assessment, and any pressure injury assessment (e.g. moisture management, impaired mobility, nutritional deficit, staging, wound characteristics). The P&P indicated Interventions will be documented in the care plan and communicated to all relevant staff.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that one of three sampled residents (Resident 1) remained continent of his bowel and bladder when they did not develop an individualized toileting program, gave Resident 1 incontinent briefs (adult diapers) instead of offering toileting, and staff did not provided required assistance for toileting. This resulted in Resident 1 becoming incontinent of his bowel and bladder and put Resident 1 at risk for infections, skin breakdown and a loss of dignity. Findings: A review of the facility's policy and procedures (P&P) titled, Urinary Incontinence-Clinical Protocol, revised 4/1/18, indicated, .the nurse shall assess and document/report the following .Whether this is a change in customary pattern since last physician visit. The P&P indicated, .nursing staff will identify, and document circumstances related to the incontinence The P&P indicated, The staff and physician will identify individuals who are continent but have risk factors for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provided one out of three sampled residents (Resident 1) with adequate pain control when: 1. Licensed Nurses (LN) did not recognize that Resident 1's repeated use of PRN (as needed) pain medication indicated the need to assess the current pain medication regimen and consult with the physician regarding scheduled pain medication. 2. Resident 1's pain was not adequately assessed upon admission to the facility when Licensed Nurse(LN) A documented that Resident 1 did not require a pain assessment interview. This failure had the potential for pain to go unrecognized and to cause a decline in physical, mental, psychosocial health, and well-being. Findings: 1. A review if the facility's policy and procedure (P&P) titled, Pain Assessment and Management, revised 10/1/22, indicated, staff would Assess the resident at admission and during ongoing assessments to help identify the resident who is experiencing pain or for whom pain may be anticipated during specific…

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 3 of 4 sampled residents who were reviewed for timely medication administrations, were given their medications in accordance with the facility's Administering Medication policy when medications were not given within 1 hour before, or within 1 hour after, the time their physician prescribed the medication to be given. (Resident 1, 3, and 4). This caused Residents 1, 3, and 4 unnecessary pain, anxiety, and interrupted their sleep and gave them feelings of being ignored and lowered their self-worth, which negatively impacted their quality of life. Findings: During a review of facility policy titled, Administering Medications, dated 4/2019, indicated Medications are administered within one ( 1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). Medications are administered in accordance with prescriber orders, including any required time frame. During an interview with 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 interview, and record review, the facility failed to ensure three out of 10 sampled residents, (Resident 1, Resident 5, and Resident 7) resident rights were protected and were treated with respect and dignity when: 1. Licensed Nurse (LN) B was argumentative with Resident 1 while administering medications. 2. Certified Nursing Assistant (CNA) D was rough while providing incontinent care to Resident 5. 3. CNA D was rude and disrespectful when Resident 7 asked for a cup of coffee. This failure had the potential to cause embarrassment as well as depression and did cause a loss of respect and dignity as well as anger. Findings: 1. A review of the facility ' s policy titled Promoting/Maintaining Resident Dignity, revised 2/2023, indicated it is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident ' s quality of life by recognizing each…

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 three allegations of abuse, to three residents (Resident 1, Resident 5, and Resident 7) out of 10 sampled residents and failed to conduct a thorough investigation and report it within five days, to the California Department of Public Health (CDPH) when: 1. Licensed Nurse (LN) B was argumentative with Resident 1 while administering medications. 2. Certified Nursing Assistant (CNA) D was rough while providing incontinent care to Resident 5. 3. CNA D was rude and disrespectful when Resident 7 asked for a cup of coffee. This failure had the potential to result in abuse to other residents in the facility. Findings: A review of a facility ' s policy revised April 2021, titled Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, indicated residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This facility ' s policy included but is not limited to freedom from corporal…

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 and immediate investigation of alleged abuse, prevent further potential abuse or mistreatment while the investigation was in progress, and provide complete and thorough documentation for three residents (Resident 1, Resident 5, and Resident 7) out of 10 sampled residents when: 1. Licensed Nurse (LN) B was argumentative with Resident 1 while administering medications. 2. Certified Nursing Assistant (CNA) D was rough while providing incontinent care to Resident 5. 3. CNA D was rude and disrespectful when Resident 7 asked for a cup of coffee. This failure had the potential to result in abuse to other residents in the facility. Findings: 1. A review of a facility ' s policy revised April 2021, titled Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, indicated residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This facility ' s policy included but is not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to evaluate, assess, and provide wound care treatments for pressure ulcers (refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. A pressure ulcer will present as an open ulcer, the appearance of which will vary depending on the stage and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear) for three of three sampled residents (Residents 1, 2, and 3). 1. Resident 1's treatments were not done as ordered by his physician. 2. Resident 2's treatments were not done as ordered by her physician and wound assessments were not done in accordance with facility policy and practice. 3. Resident 3's treatments were not done as ordered by his physician and wound assessments were not done in accordance with facility policy and practice. These failed practices had the potential to result in the worsening…

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 three out of four sampled residents (Residents 4, 5, and 6), medications in accordance with their Medication Administration policy when: 1. Residents 4, 5 and 6 were not given their medications within the time frames allowed, therefore, received them later than they should have. 2. Licensed Nurses (LN) C and LN D had not documented when they administered Resident 6's medications until the end of their shifts, instead of when they were actually given. 3. The facility did not have a backup system in place for LNs to be able to administer medication in a timely manner when there was an internet failure on 1/20/24, and LNs were not able to access the Medication Administration Record (MAR, document that described what medications were to be provided to each resident and at what time), and Resident 5 received medications five hours and 35 minutes late. These failures had the potential to cause harm and negatively impact resident ' s physical, mental,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide one out of three sampled residents (Resident 3) with the right to be fully informed (having knowledge) of care to be provided and resident rights when the facility did not obtain a Consent to Treatment (a document that was reviewed during the admissions process, that outlined resident rights and described care the resident would receive from the facility). This failure caused Resident 3 and Family Member (FM) 1) to not have knowledge of basic resident rights or care that would be provided. Findings: A review of Resident 3 ' s undated admission Record, indicated Resident 3 was admitted to the facility on [DATE] with the diagnosis of Dementia (a disease that caused memory loss over time). During an interview on 1/24/24 at 4:24 pm, FM 1 stated, when Resident 3 was being admitted to the facility, the admissions nurse asked FM 1, if FM 1 was signing the admission documents. FM 1 stated, FM 1 would sign the admission documents and asked 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 interview and record review, the facility did not follow their Resident Council Meetings (A group of residents who meet monthly to discuss concerns about living in the facility), policy and procedure when, Resident Council Minutes forms were not utilized and there was no documentation that indicated the facility followed up on resident concerns or recommendations. This failure had the potential to negatively impact resident rights and not accurately capture identified resident concerns or recommendations. Findings: During a review of the facility ' s undated policy and procedure (P&P) titled, Resident Council Meetings, the P&P indicated, This policy provides guidance to promoting structure, order, and productivity in these group meetings. The P&P indicated, the Activities Director (AD) could be elected to take and maintain Resident Council meeting notes. The P&P indicated Meeting minutes may include, but are not limited to: . Follow up from previous meetings, . Issues discussed, .and Recommendations from the group to facility staff. The P&P indicated the facility shall act…

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 two out of four sampled residents (Resident 1 and 2) from abuse when; Certified Nurse Assistant (CNA) B provided care that was rough and painful. This failure had the potential to cause harm and caused Resident 2 to have short term feelings of fear, anger, and helplessness. Findings: During a review of the facility ' s undated policy and procedure (P&P) titled, Abuse, Neglect and Exploitation, the P&P indicated, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse During a review of the facility's Follow up on Abuse report, for Resident 1, dated 1/22/24, the Follow up on Abuse report indicated, Resident 1 alleged that CNA B was rough when CNA B put Resident 1 onto the commode (a portable toilet). During a review of Resident 1 ' s undated admission Record, the admission Record…

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

Based on interview and record review, the facility failed to report an allegation of alleged staff to resident abuse to the California Department of Public Health (CDPH) within two hours for one out of three sampled residents (Resident 1) when Resident 1 reported Certified Nurse Assistant (CNA) B was rough during care and caused Resident 1 pain on 1/18/24 and the facility did not report to CDPH until 1/19/24. This failure caused a delay in the investigation process and placed resident's at risk for potential abuse. Findings: During a review of the facility ' s undated policy and procedure (P&P) titled, Abuse, Neglect and Exploitation, the P&P indicated, Reporting of alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified time frames .immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury During an interview on 1/30/24 at 11:05 am, Director of Rehab (DOR) stated…

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 in interview and record review, the facility failed to follow their Abuse policy and procedure (P&P), when an allegation of staff to resident abuse was not thoroughly investigated for one out of three sampled residents (Resident 1). This failure placed residents that lived in the facility at risk for further potential abuse. Findings: During a review of the facility ' s undated P&P titled, Abuse, Neglect and Exploitation, the P&P indicated, Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations would be included in the investigation of alleged abuse. The P&P indicated the facility would provide .complete and thorough documentation of the investigation. During a review of Resident 1 ' s IDT-Care Conference Summary, dated 1/18/24, the IDT-Care Conference Summary indicated, Resident 1 made an allegation of staff to resident abuse. The IDT-Care Conference Summary indicated Certified Nurse Assistant (CNA) B was rough with Resident 1 while providing care. During a review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to report an allegation of abuse, to one resident (Resident 7) out of 12 sampled residents and failed to report the abuse within 2 hours, to the California Department of Public Health (CDPH). This failure had the potential to result in abuse to other residents in the facility. Findings: A review of a facility ' s policy revised April 2021, titled Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, indicated residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This facility ' s policy included but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse. This facility ' s policy also indicated, The administrator or designee will notify Law Enforcement, LTC (long term care) Ombudsman, and CDPH Licensing and Certification by telephone immediately or as soon as practicable, and in writing within 24 hours, including…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to develop a base line care plan within 48 hours for five of five sampled residents (Resident 2, 25, 28, 29, and Resident 30). This failure had the risk to not meet the individual needs of the residents and cause a negative clinical outcome. Findings: The facility ' s policy revised March 2022, titled, Care Plans-Baseline, indicated a baseline plan of care to meet the resident ' s immediate health and safety needs is developed for each resident within 48 hours of admission. This facility ' s policy also indicated the base line care plan included instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident. During a review of Resident 2 ' s medical record, the admission Record, indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included Peripheral Vascular Disease…

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 6 of 6 sampled residents (Residents 2, 5, 6, 7, 11 and Resident 39), received assistance with activities of daily living (ADLs, activities related to personal care including bathing/showering, dressing, hygiene, and grooming), to attain or maintain their independence when routine and scheduled showers and nail care were not completed for residents. These failures had the potential to result in residents feeling depressed with poor self-esteem, and had the potential to contribute to skin breakdown, infection, and negatively impact their ability to attain or maintain their highest practicable level of well-being. Findings: A review of the facility ' s policy titled, Bath, Shower/Tub, revised on 2/2018 indicated the purposes of this procedure are to promote cleanliness, provide a comfort to the resident, and to observe the condition of the resident ' s skin. This facility ' s policy also indicated to Notify the supervisor if the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure there was sufficient staff to meet the needs of the residents when: 1. Showers/Bathing and nail care were not completed as scheduled for December 2023. (Refer to F677) 2. Resident 39 had not received finger nail cleaning and trimming. 3. Certified Nursing Assistants (CNAs) were unable to attend to a resident's (Resident 7) request to go back to bed, because there were not enough CNAs to pass meals trays and help feed residents. These failures had the potential to result in residents feeling ignored and neglected and could negatively impact their ability to attain or maintain their highest practicable level of physical, mental, and psycho-social well-being. Findings: During a review of the Payroll Based Journal (PBJ, a government mandated electronic submission of staffing), Fiscal Year Quarter 1: (October 1 through December 31, 2023) indicated, Weekend staffing data is excessively low for the facility. 1. During a record review 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.

During observation, interview and record review, the facility failed to ensure that the Licensed Nurses (LNs) were competent and had the skills and knowledge base to provide quality care to the residents and that these competencies and skills were evaluated when: 1. The LNs were not aware of the facility's policies and procedures on how to order and re-order medications and the residents went without medications. Refer to F755 2. The LNs were not aware that Certified Nursing Assistants (CNAs) cannot apply oxygen to residents. Refer to F695 3. LNs did not have their competencies and skills evaluated to determine their knowledge base. These failures had the potential to result in residents receiving substandard quality of care and their needs unmet and result in their inablility to attain or maintain their highest practicable level of physical, mental, and psychosocial well-being. Findings: 1. During a review of the facility ' s policy and procedure titled, Medication Ordering And Receiving From Pharmacy, Section IC3, revised 1/1/23, indicated, Medications and related products are…

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 nursing schedule review, the facility failed to ensure that there was a Registered Nurse (RN) on duty 8 hours per day, 7 days a week. This failure had the potential to adversely affect oversight and direction regarding residents ' quality of care and quality of life directly impacting overall health and well-being. Findings: A review of the Payroll Based Journal (PBJ, an electronic system for facilities to submit staffing information), for Fiscal Year Quarter 1: (October 1 through December 31, 2023), indicated four or more days within the quarter with no RN hours. During a review of the RN monthly schedule, dated October, November, and December 2023, indicated there was no RN coverage for Saturdays or Sundays during the months of October, November, and December 2023. The monthly schedules also indicated there was no RN coverage from 12/18/23 through 12/20/23. During an interview on 12/20/23 at 9:24 am, the Administrator confirmed there were no RN hours on every weekend for Saturday and Sunday October 2023, (since re-opened October 16, 2023), through December…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement their Infection Control Program policies and procedures for controlling and reporting communicable diseases and infections when; 1. Resident 21 was positive for Covid (a serious respiratory infection), and allowed to wander about the facility without a mask. 2. Licensed Nurse (LN) M was positive for Covid before her shift began on 12/16/23, and had symptoms, and worked taking care of residents, and then worked again on 12/19/23. These failures put the residents, staff and families at risk for contracting Covid infections and had the potential to result in serious negative clinical outcomes for this vulnerable population. Findings: 1. During a review of Resident 21 ' s medical record, the admission Record, indicated Resident 21 was admitted to the facility on [DATE] with diagnoses that included dementia (a term for for impaired ability to remember, think, reason, or make decisions that interfere with daily life), high blood…

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 that one of two sampled residents (Resident 1), was seen and evaluated by a Licensed Nurse (LN), upon admission, to ensure that he was being given oxygen in accordance with his physician's orders. This failure had the potential for a negative clinical outcome. Findings: During a review of the facility ' s policy revised 10/2010, tilted, Oxygen Administration, indicated the purpose of this policy is to provide guidelines for safe oxygen administration. This facility ' s policy also indicated to verify physician ' s order for this procedure. Review the resident ' s care plan to assess for any special needs of the resident, and assemble the equipment and supplies needed. During a review of the facility ' s policy revised 10/2010, tilted, Oxygen Administration, indicated the purpose of this policy is to provide guidelines for safe oxygen listing separate steps for oxygen administration procedure: Place an Oxygen in Use sign on the outside of the…

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

Based on interview and record review, the facility failed to implement its abuse policy related to training and screening of newly hired staff. 1. The criminal background search was not done for one of eight newly hired employees. This had the potential that the facility may have hired an employee who had been found guilty of abuse and expose all residents to abuse. 2. The abuse training was not done for four of eight newly hired employees. This had the potential to cause employees not to recognize or report resident abuse. Findings: A review of the facility's Abuse Prevention Program policy, dated 12/2016, indicated: As part of the resident abuse prevention, the administration will: 2. Conduct employee background checks and will not knowingly employ or otherwise engage any individual who has: a. Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law. 4. Require staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, and handling…

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 their established menu and associated recipe, during a breakfast observation on 11/14/19. This failure had the potential to lead to unintentional weight loss, or residents experiencing a decreased level of satisfaction in terms of their expectations for the food being served. Findings: During a tray line (the process of the resident's food being plated) observation on 11/14/19, starting at 7:30 am, the following items were observed being served; biscuit and gravy, fruit salad, hot oatmeal, and blended juice. The fruit salad consisted of; mandarin orange slices, peaches, pears, and sliced strawberries. The facility's posted menu titled, Good for Your Health Menus, indicated that a 'creamy tropical fruit,' would be served at breakfast on 11/14/19. The facility's recipe titled, Creamy Tropical Fruit, indicated that this fruit salad would include flavored or vanilla yogurt, and a flaked coconut garnish. During a concurrent interview and observation, following the conclusion of tray line, on 11/14/19 at…

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 document review, the facility failed to maintain a clean and orderly environment in the dietary department; when there were multiple areas of peeling paint, and a rusted ceiling vent, above where the clean dishes were stored in the dishwashing area. These failures could lead to the spread of infections, communicable diseases, and food borne illness to all residents who are served out of this kitchen. Findings: During observations in the dietary department from 11/12/19 through 11/14/19, the following was observed: * The ceiling vent located directly above the dishwasher had a visible build-up of rust colored material. * Three areas of the ceiling located directly above where the clean dishes are stored to dry, after they are finished being washed, had visible paint bubbling and peeling off. The above findings were verified during a concurrent interview and observation, with Dietary Staff (DS) 1 on 11/14/19 at 8:25 am. DS 1 acknowledged the items needed to be cleaned, and repainted in order to prevent the accidental contamination of the clean…

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: 1. Follow physician's orders for wound care for two of four sampled residents (Residents 5 and 14). with wounds resulting from pressure and/or shear (a strain in the skin structure produced by pressure, when its layers are laterally shifted in relation to each other); 2. Identify a buttocks shear wound as a pressure related injury, resulting in completing a non-pressure ulcer skin condition record, and omitting documenting of the wound as a stageable pressure injury, (Resident 5) and 3. Complete weekly comparable pressure wound assessments when pressure wound documentation was omitted completely and/ or different staff measured wounds in an inconsistent manner (Resident 5). These failures had the potential that pressure and shear related injuries could worsen when appropriate and consistent care was not provided (Refer to F725). Findings: The facility procedure titled Wound Care, dated 1/2002, read that the nurse is to verify that a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide sufficient and competent staff when: 1. Five of six confidentially interviewed residents, and Resident 4, reported short staffing causing call light response delays and delays in care when staff were busy, and 2. Current licensed nursing staff (Licensed Vocational Nurses) were not sufficiently trained to consistently identify, document, and measure wounds (refer to F686). These failures had the potential that resident care was delayed or not met, and that wound evaluations were not comparable. Findings: 1. During a record review of Resident Counsel minutes (the record of a group of facility residents who meet monthly to help identify issues that the facility could work to resolve) on 11/12/19, staffing concerns were identified on 6/24/19 when it read that not all staff listen and help and on 7/25/19 when call lights were having problems being answered timely. Resident 4's record was reviewed. Resident 4 was admitted on [DATE] with diagnoses…

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 physician ordered tele-psychiatry consultation services when follow up appointments were not scheduled for one of two sampled residents receiving the services (Resident 11). This failure had the possibility that the expertise of the consulting psychiatrist would not be available for the prescribing physician to consider when prescribing and renewing psychiatric medications. Findings: Resident 11's record was reviewed. Resident 11 was admitted to the facility on [DATE] with diagnosis that included dementia with behavioral disturbance (including self-injurious behavior and injurious behaviors directed toward others), unspecified psychosis (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality), pain and anxiety. Resident 11's current physician's orders, dated 5/31/18, and renewed monthly through 10/29/19, identified that she was to receive Psychiatric Consult and care as…

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

Based on observation, interview, and document review, the facility did not provide 80 square feet per resident, as required by regulation, in 12 resident rooms (Rooms 1, 2, 3, 4, 5, 17, 18, 19, 20, 21, 22, and 23). This had the potential to result in inadequate space for care or services to be provided to residents residing in these rooms. Findings: During the entrance conference on 11/12/19 at 10:05 am, a copy of the waiver for the reduced bedroom sizes, granted to the facility, by the Centers for Medicare & Medicaid services was discussed and reviewed with the Administrator. There was no expansion since the last survey. A copy of the resident roster indicated rooms 2, 18, 19, 20, and 21 had three residents per room. (Rooms 1, 3, 4, 5, 17, 22, and 23 had two residents per room.) Throughout the survey it was observed that residents in rooms 2, 18, 19, 20, and 21 had a reasonable amount of privacy and there was sufficient room to provide nursing care and services. The residents had adequate space for their belongings and furniture without overcrowding of over-bed tables. There were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to complete an activities assessment and personalized activities care plan for one of 12 residents (Resident 31). This resulted in a delay in recognizing the activity preferences and interests for Resident 31 and had the potential to result in boredom and a psychosocial decline. Findings: A review of Resident 31's record indicated she had been admitted on [DATE] with diagnoses that included dementia, high blood pressure, and muscle weakness. The physician noted in his admission orders that she was incapable of making healthcare decisions and her daughter was listed as her Responsible Party (RP). No activities assessment or activities care plan could be found in the record. During an interview on 11/12/19 at 3:48 pm, Resident 31's RP said her mother likes music and likes to visit with other residents but does not like TV, games, or crafts. RP said she had not seen her mother participate in many activities since her admission. RP confirmed she…

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

Based on observation, interview and record review, the facility failed to ensure proper storage of medications when the E-kit (emergency kit that contain frequently used medications that needed to be given right away) was opened with 3 medications removed without notification of the pharmacy for replacement of the drugs. This failure had the potential of drugs not being available for administration to residents during an emergency. Findings: During an observation of the medication storage room on 11/13/19 at 11:00 am with LVN B, the E-kit located in the medication room refrigerator had a yellow tag, denoting that it had been opened. Upon inspection of the opened E-kit with LVN B, 3 white copies of the E-kit sign-out record indicated Nitroglycerine (medication used to prevent chest pain) 0.4 milligrams (mg) had been removed on 11/5/19, Sodium Polystyrene (medication used to treat high blood potassium) 15grams per 60 milliliters had been removed on 11/7/19 and Micro-K (Potassium Chloride, a medication used to treat and prevent low blood potassium) 10 mg had been removed on 11/12/19.…

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 up on a pharmacy drug regimen review (DRR) recommendation for one of six sampled residents reviewed for unnecessary medication (Resident 11). This failure had the potential that pharmacy recommendations for Gradual Dose Reductions (GDR) were not acted upon and that medications may not be at the lowest dose necessary. Findings: A facility pharmacy policy titled Consultant Pharmacist Reports, dated 3/4/14, read Recommendations are acted upon and documented by the facility staff and/or the prescriber. 1. Physician accepts and acts upon suggestions or rejects and provides an explanation for disagreeing . Resident 11's record was reviewed. Resident 11 was admitted to the facility on [DATE] with diagnosis that included dementia with behavioral disturbance (including self-injurious behavior and injurious behaviors directed toward others), unspecified psychosis (a severe mental disorder in which thought and emotions are so impaired 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 interview and record review, the facility failed to comply with its antibiotic stewardship program, when one of two residents (Resident 21) with urinary tract infections (UTIs), during the months of 9/2019 and 10/2019, were treated without associated signs and symptoms. This had the potential to result in unnecessary antibiotic usage and adverse side effects. Findings: A review of Resident 21's record indicated she was admitted on [DATE] with diagnoses that included lung disease and dementia. She had received Rocephin (antibiotic) to treat a UTI during 10/2019. During a concurrent interview and record review on 11/13/19 at 2:32 pm, the Infection Control Nurse (ICN) confirmed a nurse's note, dated 10/19/19 at 6:30 pm, indicated Resident 21 had not voided that shift. The physician was notified and ordered a urine culture and sensitivity (C&S) and Rocephin. ICN confirmed the C&S collected on 10/19/19, showed bacteria that could be treated by the antibiotic given to Resident 21. A copy of the C&S 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.