Shields Richmond Nursing Center

Based on observation, interview and record review, the facility failed to assist in maintaining a sufficient food and fluid intake for one of three sampled residents (Resident 5) when Resident 5's poor meal and fluid intake were not addressed in a timely manner to maintain proper nutrition and hydration. This failure resulted in dehydration (dangerous loss of body fluid causes by illness or inadequate fluid intake) and potential for malnutrition (condition that develops when the body is deprived of vitamins, minerals and other nutrients it needs to maintain healthy tissues and organ function) and further decline in Resident 5's health condition. Findings: A review of Resident 5's admission Record, printed on 4/16/25, indicated Resident 5 was admitted to the facility in March 2025 with multiple diagnoses of Alzheimer's disease (a progressive brain disorder that primarily affects memory, thinking, and behavioral abilities), severe protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure staff had the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident when Registered Nurse (RN) 2, who failed to observe infection control procedures for contact precautions and identify a change in resident's bowel elimination status, did not complete annual competency/skills evaluation. This failure had the potential to result in unsafe resident care. Findings: During review of Resident 169's admission Record, the admission Record indicated Resident 169 was admitted to the facility on [DATE] with diagnoses that included enterocolitis (an inflammation of both the small and large intestines. It can be caused by various factors, including bacterial infections) due to Clostridium difficile (C. diff, a bacteria that can cause diarrhea and colitis, an inflammation of the colon) infection.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, for one of one sampled resident (Resident 59) reviewed for psychotropic (any drug that affects brain activities associated with mental processes and behavior) medication use, the facility failed to ensure Resident 59 received antipsychotic medication (treats mental disorders, including schizophrenia and bipolar disorder) with appropriate indication. This failure had the potential to result in unnecessary adverse reactions from the medication. Findings: During a review of Resident 59's admission Record, the admission Record indicated Resident 59 was admitted to the facility in February 2025 with diagnoses that included metabolic encephalopathy (a brain disorder resulting from imbalances in the body's chemical or electrolyte levels, leading to brain dysfunction), Alzheimer's dementia (a general term for the decline in memory and other cognitive abilities that interfere with daily life), major depressive disorder (a mental disorder characterized by persistent sadness, loss of interest or pleasure, and other symptoms that significantly…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure infection prevention and control procedures were followed when: -Housekeeping Aide (HA) did not disinfect Resident 169's room, a contact precaution (a set of infection control practices used to prevent the spread of germs through direct or indirect contact. These precautions are implemented when a patient has a disease that can be transmitted by touching the patient, contaminated surfaces, or objects in their environment) room, with appropriate disinfectant. -Registered Nurse (RN) 1 did not disinfect medical device with appropriate disinfectant in between resident use. This failure had the potential to result in spreading Clostridium difficile (C. diff, a bacteria that causes diarrhea and colitis (inflammation of the colon). It's a serious infection that can be life-threatening, especially in vulnerable populations like older adults in healthcare settings) infection to other residents. Findings: During a review of Resident 169'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 interview and record review, for one randomly selected resident (Resident 369), the facility failed to establish and implement infection prevention and control program that included antibiotic stewardship program when: -Resident 369 was administered antibiotics without adequate indication. -Resident 369's possible symptoms of antibiotic side effects were not monitored. This failure had the potential to result in the development of antibiotic-resistant infections (occur when bacteria develop the ability to withstand the effects of antibiotics, making them difficult or impossible to treat, can be serious and even life-threatening, often requiring longer hospital stays, more expensive treatments, and potentially toxic medications). Findings: During a review of Resident 369's admission Record, the admission Record indicated Resident 369 was admitted to the facility in March 2024 with diagnoses that included hypertension (high blood pressure) and personal history of urinary tract infection. During a review of Resident 369's Minimum Data Set (MDS, an assessment tool used 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 maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for one of three sampled residents (Resident 1) when Treatment Nurse 1 (TN 1) did not perform hand hygiene (handwash with soap and water or alcohol-based hand rub) in between glove changes during the wound dressing change. This failure had the potential to result in infection and spread of infection. Findings: A review of Resident 1s admission Record, printed 12/11/24, indicated resident was readmitted to the facility on [DATE] with diagnosis of diabetes mellitus (high blood sugar). A review of Resident 1's Physician Order, with a revision date of 12/5/24, indicated a treatment order for resident's sacral region (the triangular shaped bone at the base of the spine that connects the spine to the pelvis) Stage III pressure ulcer (a full…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 dental services to meet the needs of two of three sampled residents (Resident 2 and Resident 3) when: 1. The facility failed to promptly refer Resident 2 for dental services, within three days as required, when Resident 2's tooth was chipped. 2. The facility did not provide timely dental services to obtain full dentures for Resident 3. These failures had the potential to result in decreased food intake and potential significant weight loss for both residents. Findings: 1. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility in May 2023 with diagnoses that included moderate protein-calorie malnutrition. During a review of Resident 2's Medication Review Report (MRR), the MRR indicated an order, dated 5/11/23, for Resident 2 to have dental consult with treatment and follow-up as indicated, and for Resident 2 to have regular, fortified diet regular texture and thin liquids. During a review of Resident 2's Dental Notes, dated 7/9/24, the Dental Notes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of two residents (Resident 1) was free from physical abuse when Resident 2 repeatedly hit Resident 1 on the left lower extremity. This failure had the potential to result in physical injury and psychosocial harm. Findings: During a review of Resident 1's Face Sheet, undated, the Face Sheet indicated Resident 1 was admitted to the facility in March 2021 with diagnoses that included Alzheimer's dementia (a loss of brain function that occurs with certain diseases, affecting one or more brain functions such as memory, thinking, language, judgment, or behavior), severe open-angle glaucoma (group of eye conditions that damage the nerves in the eye causing visual impairment), and type 2 diabetes mellitus (a long-term [chronic] disease in which the body cannot regulate the amount of sugar in the blood). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in…

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

Based on staff interviews and review of facility documents, the facility failed to comply with Federal regulations related to the oversight of food service operations when the facility did not have a full-time dietitian and the requirements were not met as specified in established standards (California Code, Health and Safety Code - HSC § 1265.4) for food service managers which required, employment of a full-time, qualified dietetic supervisor when the dietitian was not full time. The lack of a qualified, competent, and full-time supervisor resulted in staff not having adequate supervision, training, and knowledge to carry out Food and Nutrition Services in a safe and sanitary manner. The lack of qualified, full time person to supervise the Food and Nutrition Services Department had the potential to result in unsafe food practices and food borne illness for 58 residents eating facility prepared foods. Findings: According to the California Code, Health, and Safety Code - HSC § 1265.4: A licensed health facility shall employ a full-time, part-time, or consulting dietitian. A health…

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

Based on observation, interview, and facility document review, the facility failed to ensure kitchen staff were competent regarding job duties when: 1. A cook did not know the appropriate method for manually cleaning soiled utensils and equipment using the 3-compartment sink. 2. A diet aide did not know the appropriate procedures for testing the strength of the sanitizer solution used for sanitizing kitchen surfaces. 3. A diet aide did not demonstrate appropriate procedures for testing the sanitizer in the dish machine. These failures had the potential to result in contamination of kitchen equipment and/or utensils leading to illness caused by pathogens (harmful organisms) for 58 residents who received food from the kitchen. Findings: 1. During a concurrent observation and interview on 12/05/23 at 10:35 a.m. with [NAME] 2, [NAME] 2 stood by the 3-compartment sink and described the process for cleaning soiled utensils/equipment in the sink. He stated the first sink was filled with water only, the second sink was filled with water and soap, and the third sink was filled with…

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

Based on observation, interview, and facility document review, the facility failed to ensure: 1. the menu met the nutritional needs of the residents; 2. there was a menu for a vegetarian diet; and 3. portions for diets provided matched what was indicated in the diet manual. These failures had the potential for residents to receive meals containing nutrients at levels not appropriate for their prescribed diet leading to food related medical complications for 58 residents who received food from the kitchen. Findings: 1. Per the National Institute of Health, Nutrient Recommendations: Dietary Reference Intake (DRI) are documents issued by the Food and Nutrition Board of the National Academies of Sciences Engineering, and Medicine. DRI is the general term for a set of reference values used to plan and assess nutrient intakes of healthy people. These values, which vary by age and sex, include Recommended Dietary Allowance (RDA): the average daily level of intake sufficient to meet the nutrient requirements of nearly all (97-98%) healthy individuals and often used to plan nutritionally…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 serve food that was palatable when food was bland (lacked flavor). This failure had the potential to negatively impact the residents' dining experience which may result in poor dietary intake compromising the health and nutritional status of 58 residents who received food from the kitchen. Findings: During an interview on 12/04/23 at 10:45 a.m. with Resident 16, Resident 16 stated the facility's food was lacking in taste and beans were very plain. During a review of daily menu, dated 12/04/23, the lunch menu indicated green beans were served for all diets. During a concurrent observation and interview on 10/04/23 at 12:50 p.m. with Registered Dietitian Nutritionist (RDN), a test tray was conducted. The test tray contained the same regular textured and pureed food served to residents for lunch. The food was tasted by three surveyors and the RDN. All the surveyors and the RDN agreed the green beans for both regular and pureed were lacking flavor. During a review of daily menu dated 12/05/23, the lunch menu…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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: 1. Provide an alternate vegetarian entrée of similar nutritive value to the regular entrée for one non-sampled resident (Resident 57). 2. Ensure peanut butter and jelly sandwiches offered as an alternate entrée were of similar nutritive value to the regular entrée. These failures had the potential to result in a decreased nutrient intake as indicated by the planned menu for 29 residents who received Regular textured food. Findings: 1. A review of Resident 57's admission Record, printed 12/08/23, showed Resident 57 was originally admitted in August 2023 with diagnoses of anemia (lack of red blood cells), diabetes (too much sugar in the blood), depression, and muscle weakness. A review of Resident 57's Order Details, dated 08/24/23, showed Resident 57 had an order for a vegetarian diet placed by a primary care physician. During a review of Resident 57's lunch tray ticket, dated 12/04/23, the ticket showed Resident 57 was on a vegetarian diet. During a review of the facility's menu spreadsheet,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, and serve food in accordance with professional standards for food safety when the following was noted: 1. A 10-pound roll of ground beef and a 10-pound package of sausage were not thawed safely. 2. A juice dispenser was not clean. 3. A can opener was not clean. 4. Three cutting boards were not in a good condition and were not clean. 5. Dry food was not stored at least six inches off the floor. 6. Three pans were in poor condition. 7. A lowerator (plate warmer) was not clean. 8. A fan mounted to the wall inside the kitchen was not clean. 9. A vent inside the dry food storage closet was not clean. 10. The floor of three food storage/ supply closets located in the hallway, outside of the kitchen, had a rough, crumbling surface where transition strips (a long strip made of metal, wood, or other material, with rounded edges, used to bridge two floors together) were missing. 11. The handwashing sink was used for another purpose other than handwashing. 12. Expired test strips were available and used…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 have a policy and procedure to describe how food brought in by family and visitors would be stored safely for the residents. This failure had the potential to negatively impact the residents' dining experience and possibly result in poor food intake for 58 residents who ate food by mouth. Findings: A review of the policy and procedure titled Foods Brought by Family/Visitors with a revision date of October 2017, showed food brought to the facility by visitors and family is permitted. The staff will discard perishable food within the same day or 4-hours from the time food is brought into the facility to prevent risk of foodborne contamination. In an interview with the Director of Staff Development/Infection Preventionist (DSD-IP) on 12/7/23 at 8:25 a.m., DSD-IP stated the facility did not save/store food for residents when food was brought in from the outside by visitors and/or from restaurants because it was not known if the food was stored and/or prepared safely before it was brought into the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure four of thirty-six sampled residents (Residents 24, 25, 56 and 215) had complete and current care plans. This failure had the potential to cause residents to not receive appropriate and adequate care thereby affecting their physical and psychosocial well-being. During a concurrent interview and record review on 12/6/23 at 7:58 a.m. with Director of Nursing (DON), Resident 25's care plans were reviewed. DON stated Res 25 was hospitalized from [DATE] to 10/5/23 and was diagnosed with pneumonia. DON further stated Res 25 received antibiotics from 10/5/23 to 10/7/23. DON stated Resident 25 did not have care plans for pneumonia and antibiotic treatment and without a care plan for antibiotics, the facility would not be able to check if the antibiotic was effective and monitor for side effects. During a concurrent interview and record review at 8:30 a.m. with DON, Resident 24's care plans were reviewed. Resident 24's care plans for Risk for Pain, Risk…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 pureed food was the appropriate consistency. This failure had the potential for eight residents on pureed diet to aspirate (drawing food into the lungs) and/or negatively impact the residents' dining experience resulting in poor food intake compromising their nutritional status out of facility census of 58. Findings: Review of the Diet Manual Rehabilitation, Residential and Long Term Care Facilities, dated 2018, showed the pureed diet should be smooth and the consistency of pudding. During a review of facility's policy and procedure (P&P) titled Food Preparation .Food Cookery, dated 2018, the P&P indicated, Pureed Food Preparation .Pureed food should be prepared to the consistency and thickness of mashed potatoes rather than a gravy or watery texture. Review of the daily menu, dated 12/04/23, showed the lunch menu included a pureed diet which received pureed pork with apples, pureed sweet potato, and pureed green beans. During an observation on 12/04/23 at 12:50 p.m. with Registered Dietitian…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff followed proper infection control precautions to prevent spread of infection for five (Resident 16, Resident 55, Resident 21, Resident 60, and Resident 167) of 58 sampled residents when: 1) Resident 167's urinary catheter bag was touching the floor. 2) The nasal cannula for Resident 55 was not changed weekly. 3) The tube feeding for Resident 60 was not dated and labelled. 4) Nursing assistant (NA) did not perform hand hygiene after providing incontinent care to Resident 21. NA did not perform hand hygiene before entering and exiting resident rooms. 5) Registered Nurse 2(RN 2) did not change gloves and perform hand hygiene after handling Resident 16's device, and then gave medications to Resident 16 and applied eye drops. These deficient practices had the potential to transmit infectious microorganisms and increase the risk of infection for residents and staff. Findings: 1. During a review of Resident 167's, admission…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 80 square foot of space per resident for 30 residents who occupied 12 multi-bed bedrooms. This condition had the potential to result in lack of sufficient space for the provision of care both routine and emergency and for residents to have their personal belongings at bedside. Findings: During multiple room observations on 12/4/23 through 12/8/23, there were three residents in Rooms 22, 24, 27, 31, 33, and 35 and two residents occupying three-bedroom rooms in Rooms 23, 25, 26, 30, 32, and 34. 1. room [ROOM NUMBER] measured 11.3 feet by 19 feet which equaled 71.56 square feet per resident. 2. room [ROOM NUMBER] measured 19 feet by 11.4 feet which equaled 72.2 square feet per resident. 3. room [ROOM NUMBER] measured 19.3 feet by 11.4 feet which equaled 73.34 square feet per resident. 4. room [ROOM NUMBER] measured 19.1 feet by 11.3 feet which equaled 71.94 square feet per resident. 5. room [ROOM NUMBER] measured 19.1 feet by 11 feet…

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

Based on interview and record reviews, the facility failed to meet the needs for one of two sampled residents (Resident 167) when the facility did not develop and implement a comprehensive care plan for Resident 167 with an indwelling urinary catheter (a tube that is inserted into the bladder to drain urine). This deficient practice placed Resident 167 at risk for developing physical and psychosocial complications related to use the of urinary catheters including infection. Findings: During a review of Resident 167's, admission Record, printed on 12/7/23, the admission Record indicated Resident 167 was originally admitted to the facility in November 23 with a diagnosis of Bacteremia (Bacteremia is the presence of bacteria in the bloodstream) and chronic kidney disease (kidneys are damaged and can't filter blood the way they should and causes them to gradually lose their ability to function). During a review of Resident 167's electronic health record titled, Care plan, dated 11/11/23, the care plan indicated there was no interventions planned or implemented for the use and/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 observation, interview, and record review, the facility failed to ensure 1 of 2 sampled residents (Resident 167) had a physician order to maintain an indwelling catheter (a tube inserted into the bladder that drains urine into a bag outside the body) in place after admission and indication of a medical condition for the use of the indwelling urinary catheter. This deficient practice placed Resident 167 at risk for developing complications related to use of urinary catheters including urinary tract infection. Findings: During observation on 12/4/23 at 10:28 a.m., Resident 167 was observed with a urinary catheter in place. During a review of Resident 167's, admission Record, printed on 12/7/23, the admission record indicated Resident 167 was originally admitted to the facility in November 2023 with a diagnosis of bacteremia (the presence of bacteria in the bloodstream) and chronic kidney disease (kidneys are damaged and can't filter blood the way they should and causes them to gradually lose their ability to function). During a review of Resident 167's Physician Orders, there…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 show an Interdisciplinary Team meeting was conducted after one sampled resident (Resident 19) had severe weight loss. This failure had the potential to result in inadequate resident care for one resident out of a census of 58. Findings: A record review for Resident 19 showed he was [AGE] years old admitted in January of 2020 and had diagnoses including but not limited to Parkinson's disease, acute kidney failure, amenia, and major depressive disorder. A record review of Resident 19's weight history showed he weighed 178.4 pounds (lbs.) on 10/9/23 and on 10/30/23 he weighed 143.6 lbs., which was a 19.5 percent (%) weight loss in 21 days. Resident 19 was weighed again on 11/2/23 and his weight was 145.6 lbs. which was a 18.4 % weight loss in 24 days. A record review for Resident 19 showed Registered Dietitian Nutritionist (RDN) documented a Nutrition Assessment on 10/31/23. The documentation showed Resident 19 lost 34.8 lbs./19.5% in one month…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 dementia (progressive decline in memory that affects the ability to perform everyday activities) was developed for one of two sampled residents (Resident 167). This failure had the potential for Resident 167 to not receive the appropriate treatment and services needed to meet her dementia care needs. Findings: During a review of Resident 167's admission Record, printed on 12/7/23, the admission Record indicated Resident 167 was originally admitted to the facility in November 2023 with a diagnosis of Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks) and unspecified dementia. During a record review of Resident 167's Minimum Data Set (MDS- an assessment used to guide care), Section C, dated 11/15/23, the MDS showed Resident 167's Brief Interview for Mental Status (BIMS- cognition assessment) score was 0 out of 15, indicating severely…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and interview, the facility failed to accommodate individual needs and preferences of one (Resident 31) of three sampled residents, when Resident 31 did not have access to dietary menu. This deficient practice had the potential to affect the quality of life for Resident 31 and his needs not being met while at the facility. Findings: During a record review of admission Record, printed on 12/7/23, the admission Record indicated Resident 31 was admitted to the facility in September 2022. The admission Record indicated that Resident 32 has a medical diagnoses including hemiplegia (loss of muscle function on one side of body) and hemiparesis (weakness or the inability to move on one side of the body), following a cerebral infarction. (a lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off). During a record review of Resident 31's Minimum Data Set (MDS- An assessment used to guide care), Section C, dated 9/12/23, the MDS showed Resident 31's Brief Interview for Mental Status (BIMS-…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 follow its policy and procedure to immediately report an alleged abuse allegation to the California Department of Public Health (CDPH) for over 24 hours for one (Resident 31) of 3 sampled residents when Resident 31 alleged CNA 3 touched him inappropriately. This failure had potential risk of delay in investigation and affect physical and psychological well-being of residents. Findings: During a record review of admission Record, printed on 12/7/23, the admission Record indicated Resident 31 was admitted to the facility in September 2022. The admission Record indicated that Resident 31 had a medical diagnoses including hemiplegia (loss of muscle function on one side of body) and hemiparesis (weakness or the inability to move on one side of the body), following cerebral infarction. (a lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off). During a record review of Resident 31's Minimum Data Set (MDS- An assessment used to guide care), Section…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 complete quarterly Minimum Data Sets (MDS- an assessment tool used to quid care) timely for eight of ten sampled residents (Residents 10, 11,16, 24, 37, 40, 48, and 49). This failure had the potential to delay care planning and delivery. Findings: During a review of Resident 10's quarterly MDS, the MDS indicated, Assessment Reference Date (ARD - the last day to finish the assessment of the resident) 9/24/21, and completed on 10/26/21. During a review of Resident 10's Quarterly MDS, the MDS indicated ARD 12/25/21, completed 1/4/22. During a review of Resident 10's Quarterly MDS, the MDS indicated, ARD 3/27/22, completed on 5/10/22. During a review of Resident 11's Quarterly MDS, the MDS indicated, ARD 3/26/21, no assessment completed. During a review of Resident 11's Quarterly MDS, the MDS indicated, ARD of 5/30/21, completed on 6/23/21. During a review of Resident 16's Quarterly MDS, the MDS indicated, ARD of 3/11/2022, completed on 5/6/2022. During a review of Resident 16's Quarterly MDS, the MDSindicated, ARD of 12/9/21,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 complete the annual Minimum Data Set (MDS- an assessment tool used in skilled nursing facilities), for one of ten sampled residents (Resident 9). This failure had the potential to delay care planning and care delivery. Findings: Resident 9's annual MDS had an Assessment Reference Date (ARD - the last day to finish the assessment of the resident) of 2/28/22. The annual MDS was submitted and accepted on 5/6/22. During an interview on 5/12/22 at 9:18 a.m., with Director of Nursing (DON), DON stated, Resident 9's annual MDS was submitted late. DON stated, the MDS was required and was a reflection of the resident's condition and care. DON stated, the MDS was an assessment and could pick up changes in the resident's condition and was used to write plan care. DON further stated, staff need to have accurate assessments to provide care.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to meet the needs for one (Resident 114) of one sampled residents receiving dialysis when the facility did not develop and implement care plan for Resident 114's dialysis (treatment of kidney failure that rids your blood of unwanted toxins, waste products and excess fluids by filtering your blood) care. This deficient practice may result in Resident 114's physical, psychosocial and functional needs to go unmet. Findings: A review of Resident 114's admission Record, dated 5/11/22, the Admision Record indicated, Resident 114 was admitted to the facility on [DATE] with a diagnosis of acute respiratory failure (condition in which the lungs have a hard time loading blood with oxygen or removing carbon dioxide). During a record review of Resident 114's doctor's orders, dated 5/11/22, indicated Resident 114 receives dialysis every Mondays, Wednesdays and Fridays at DaVita El [NAME] and has a right chest wall port-a-cath (an implanted device which allows easy…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 (Resident 61), of three sampled residents, received effective oxygen therapy when staff did not assess and monitor Resident 61's use of oxygen. This deficient practice may result in ineffective oxygen therapy. Findings: A review of Resident 61's admission Record, dated 5/11/22, the admission Record indicated, Resident 61 was admitted to the facility on [DATE] with a diagnosis of seizures (a sudden, uncontrolled electrical disturbance in the brain). A review of Resident 61's Medication Review Report, dated 5/11/22, the Medication Review Report indicated, doctor's order on 2/14/2020 to start oxygen at 1 liters per minute (LPM- flow rate) as needed to titrate oxygen saturation above 90% and to wean or discontinue as tolerated by the resident. During a concurrent observation and interview on 5/10/22 at 10:11 a.m., Resident 61 was in bed receiving oxygen by a nasal cannula at 3 LPM. Registered Nurse (RN) 2 confirmed Resident 61 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide care for one (Resident 114) that required dialysis (treatment of kidney failure that rids your blood of unwanted toxins, waste products and excess fluids by filtering your blood) when staff did not do a complete assessment before Resident 114's dialysis treatment. This deficient practice resulted in an incomplete assessment of Resident 114's dialysis access site before their dialysis treatment. Findings: A review of the document titled, admission Record, dated 5/11/22, the admission Record indicated, Resident 114 was admitted to the facility on [DATE], with a diagnosis of acute respiratory failure (condition in which the lungs have a hard time loading blood with oxygen or removing carbon dioxide). During a review of Resident 114's doctor's orders, dated 5/11/22, the doctor's order indicated, Resident 114 receive dialysis treatments every Mondays, Wednesdays and Fridays at DaVita El [NAME] and has a right chest wall port-a-cath (an implanted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff performed hand hygiene between giving medications to two residents (Resident 21 and Resident 119) of 20 sampled residents This failure had the potential to cause or spread infections which can lead to hospitalization for Resident 21 and Resident 119, as well as the rest of the residents in the facility. Findings: 1. During concurrent observation and interview on 05/11/2022, at 4:08 p.m., with Registered Nurse 1 (RN1), in room [ROOM NUMBER], RN1 was observed giving medications to Resident 21. RN1 then went back to the medication cart and prepared medications for Resident 119 without performing hand hygiene. RN1 stated, she should have sanitized her hands between passing medications to different residents because it could spread infections. During an interview on 05/11/2022, at 12:05 p.m., with Director of Staff Development/Infection Preventionist (DSD/IP), DSD/IP stated, her expectation is that all staff perform hand hygiene…

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