Ridgecrest Regional Transitional Care And Rehabili

Based on observation, interview, and record review, the facility failed to enusre call lights were withing reach for four of 36 sampled residents (Resident 47, Resident 61, Resident 16, Resident 15). This failure had the potential for residents' needs to go unmet and place residents' safety at risk. Findings: During an observation on 3/3/25 at 10:53 a.m. in Resident 47's room, Resident 47 was laying on her back toward her left side and was restless, moving both feet back and forth on the mattress. Resident 47's sensitive call light (a system to be used for limited mobility) was tied to the right upper side rail where she could activate or use call for assistance. During a concurrent observation and interview on 3/3/25 at 10:56 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 47's call light was observed tied to the right upper side rail. LVN 1 stated Resident 47 was able to use the round sensitive call light and it should be within her reach. During an observation on 3/3/25 at 1:19 p.m. in Resident 61's room, Resident 61's call light was hanging over the headboard out of reach…

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 three of seven sampled residents (Resident 14, Resident 38, and Resident 56) were informed of the process to file a grievance (formal complaint) with the facility. This failure had the potential for residents' concerns to go unaddressed by the facility. Findings: During an interview on 3/4/25 at 10:04 a.m. with Resident 14, Resident 14 stated he did not know how to file a grievance. During a review of Resident 14's Minimum Data Set, (MDS- a federally mandated resident assessment tool) dated 1/17/25, the MDS indicated Resident 14 had a Brief Interview for Mental Status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 13 (score of 13-15 means cognitively intact). During an interview on 3/4/25 at 10:05 a.m. with Resident 38, Resident 38 stated she does not remember if the facility informed her on how to file a grievance. Resident 38 stated she just…

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 follow their Policy and Procedure (P&P) titled, Staffing, Sufficient and Competent Nursing, for all residents (73) when direct care service hours per patient day for Certified Nursing Assistants (CNAs) fell below the minimum standard of 2.4. This failure had the potential for residents care needs not to be met by staff. Findings: During an interview on 3/4/25 at 2:39 p.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated when staff call off from work, they work short staffed. LVN 3 stated they would divide up the tasks that would have been completed by the staff who called off work. During an interview on 3/6/25 at 9:45 a.m. with Certified Nursing Assistant (CNA) 6, CNA 6 stated she has worked short staffed frequently. During a concurrent interview and record review on 3/6/25 at 11:12 p.m. with Director of Nursing (DON), Census and Direct Care Service Hours Per Patient Day (DHPPD), dated 3/1/25 and 3/2/25 were reviewed. DHPPD indicated on 3/1/25 actual CNA DHPPD was 2.31. A signature indicated the patient census and direct…

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's Quality Assurance and Performance Improvement (QAPI) committee failed to identify, develop, and implement infection prevention and control action plans to correct infection control deficient practices identified by the survey team (Reference tags F-880, F-882 and F-945). This failure placed all 73 facility residents at risk for infectious diseases. Findings: During a concurrent interview and record review on 3/6/25 at 11:50 a.m. with the Administrator, the minutes of the facility's Quality Assurance and Performance Improvement (QAPI) (a committee that identifies quality deficits and implements corrective plans) meeting dated 1/23/25 (the most recent QAPI meeting) were reviewed. The Administrator indicated the 1/23/25 QAPI meeting covered the period of October, November, and December 2024. The facility's QAPI meeting minutes dated 1/23/25 were reviewed. The QAPI meeting minutes indicated a one page infection prevention control report titled Quarterly Report Infection Prevention 2024. The Quarterly Report 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement infection prevention and control practices when: 1. One of six sampled residents (Resident 6) had three opened gallons of distilled water on top of a commode. This failure had the potential for contamination of the distilled water. 2. Treatment Nurse (TN) dropped an item from the treatment cart, picked it up off the floor, and placed it back in the treatment cart. This failure had the potential for contamination of clean items in the treatment cart. 3. Infection Preventionist (IP) did not follow the facility's policy and procedure (P&P) titled, Monitoring Compliance with Infection Control for surveillance (monitoring) activities, collecting, analyzing, and tracking and trending of data. This failure had the potential for facility to be unaware of outbreaks and transmission of infectious diseases. 4. Enhanced Barrier Precaution (EBP-a set of infection control measures that use gowns and gloves to reduce the spread of…

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

Based on interview, and record review, the facility failed to follow its Policy and Procedure titled, Employee Training on Infection Control, for 11 of 25 sampled Licensed Vocational Nurses (LVN) (LVN 1, LVN 2, LVN 3, LVN 4, LVN 5, LVN 6, LVN 7, LVN 8, LVN 10, LVN 11, and LVN 12) and four of six sampled Registered Nurses (RN) (RN 1, RN 2, RN 4, and RN 5). This failure resulted in licensed nursing staff being unaware of standard infection prevention precautions, increasing the potential for the spread of infectious diseases to residents, staff, and visitors. Findings: During a concurrent interview and record review on 3/5/25 at 2:39 p.m. with Infection Preventionist (IP) the facility's education titled,Infection Prevention (IP), dated 6/18/24, 6/19/24, 1/24/24, and 1/25/24 was reviewed. The IP education indicated some of the topics that should have been covered during the training included: the six elements of Standard Precautions, the importance of hand hygiene, contact wet time of disinfectants, proper use of personal protective equipment, the difference between cleaning and…

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

Based on observation, interview, and record review, the facility failed to provide a home-like environment for one of six sampled residents (Resident 72) when the bathroom had an odor. This failure had the potential to cause a decrease in Resident 72 and visitors' comfort level and failed to protect Resident 72's right to a home-like environment. Findings: During a review of Resident 72's admission Record (AR), dated 12/6/25, the AR indicated, Resident 72's admission date was 12/6/25. During a concurrent observation and interview on 3/5/25 at 8:08 a.m. with Resident 72's family member (FM) in Resident 72's room, there was a strong odor of urine in the bathroom. FM stated when the bathroom door is left open, there was a strong stale urine smell. FM stated she had visited Resident 72 every day since he was admitted three weeks ago. During an interview on 3/5/25 at 8:16 a.m. with Resident 72, Resident 72 stated, The bathroom stinks. During a review of Resident 72's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 2/13/24, the MDS indicated Resident 72 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.

Based on interview and record review, the facility failed to follow its Policy and Procedure, Care Plans [CP], Comprehensive Person-Centered, when care plans were not developed and implemented for two of 38 sampled residents (Resident 32 and Resident 6) with infections. This failure had the potential to result in Resident 32 and Resident 6's individualized care needs to go unmet and negatively affect their health and recovery. Findings: During a concurrent observation and interview on 3/3/25 at 1:01 p.m. with Resident 32 in Resident 32's room, Resident 32 had an intravenous (IV- in the vein) catheter (small flexible tube used to administer medications) in his right wrist. Resident 32's room contained an IV bag labeled with an antibiotic (medication used to treat infections), with tubing attached and an IV infusion pump on a pole next to his bed. Resident 32 stated he had a urinary tract infection (UTI- microscopic organisms living in the urinary tract [bladder, ureters, urethra, or kidneys] causing pain while urinating, pain in the back or side, or needing to urinate often). During…

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

Based on interview, and record review, the facility failed to ensure one of one sampled residents (Resident 31) diet order was clarified per Resident 31's preference for lacto-vegetarian (which include dairy products but not egg products) diet, as orders are a plan of care and communication to the interdisciplinary team, including the physician responsible for the care of Resident 31. Facility failure to clarify the diet order with the physician responsible for prescribing diet orders had the potential for Resident 31's physician to be unaware Resident 31 excluded some foods that may lead to deficits in some nutrients, vitamins and minerals, in order for the doctor to evaluate if further tests or labs may be in order. Findings: During a review of Resident 31's Nutrition Risk Assessment (NRA), dated 7/16/24, the NRA indicated, Food/Cultural/Religious Preferences: Vegetarian diet -dairy ok. No eggs.Interventions; Recommend continue M/S [mechanical soft] diet as ordered.MVI [multivitamin] w/ [with] minerals requested. During a concurrent interview and record review on 03/05/25 at 11:50…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 32 and Resident 38) where not at risk for accident and injury when: 1. Resident 32's bathroom grab bar was slippery and grip tape (non-slip cover designed to maximize safety using hand hold surfaces) was not secured to grab bar. This failure had the potential to result in falls with injuries. 2. Resident 38 was left unsupervised while out on a patio and without means to call for assistance. This failure had the potential for Resident 38 to experience harm. Findings: 1. During a concurrent observation and interview on [DATE] at 1:01 p.m. with Resident 32 in Resident 32's room, a tube of silicone cream was on the resident 32's bed. In the bathroom, grab bars were on the left side of the toilet. No grip tape was on the grab bars. Resident 32 demonstrated how his hands slipped on the grab bars. Resident 32 stated his hands are slippery from silicone cream. Resident 32 stated the facility had put…

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 monitor the effectiveness of pain medications for two of two sampled residents (Resident 35 and Resident 55). This failure had the potential for Resident 35 and Resident 55 to experience uncontrolled pain. Findings: During an interview on 3/3/25 at 10:50 a.m. with Resident 35, Resident 35 stated she had uncontrolled pain. During a review of Resident 35's Order History (a record of the resident's current medication orders), undated, the Order History indicated the following order: Dilaudid [a narcotic pain medication] 2 mg to be administered every 6 hours as needed for pain. During an interview on 3/3/25 at 11:32 a.m. with Resident 55, Resident 55 stated she had uncontrolled pain. During a review of Resident 55's Order History, undated, the Order History indicated the following order: Norco [a narcotic pain medication] 5/325 mg [milligrams] to be administered every 6 hours for pain. During a concurrent interview and record review on 3/6/25 at 7:53 a.m. with the DON, Resident 55's medication MAR, for the period 3/4/25 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.

Based on observation, interview, and record review, the facility failed to ensure insulin (a medication to control blood sugar levels) vials were labeled with the resident's name for one of one sampled Resident (Resident 36). This failure had the potential for Residents 36 to receive another resident's insulin. Findings: During a concurrent observation and interview on 3/5/25 at 11:20 a.m. with Licensed Vocational Nurse (LVN) 1, during medication pass, LVN 1 was preparing to administer insulin to Resident 36. LVN 1 opened a drawer in the medication cart and removed a box labeled with Resident 36's name and Humulin (insulin used to treat high blood sugar) R ]Regular] 100u/mL [unit/milliunits-units of measure] Solution - Inject before meals LVN 1 opened the box and pulled a vial labeled Humulin REGULAR (Insulin Human) Injection. The vial did not have resident 36's name or other resident identifying information. LVN 1 stated each resident receiving insulin had their own dedicated insulin vial, but the resident's name was placed only on the outside box and not on the vial. During an…

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. The planned menu for a therapeutic renal diet (for kidney disease) was followed for one of one sampled resident (Resident 43) when 2 oz. (ounces) of gravy was served instead of 1 oz. of gravy as planned. This failure had the potential for Resident 43 to not have her their individualized nutritional needs met. 2. A Registered Dietitian (RD) developed and prepared a lacto [dairy okay]-vegetarian menu to include an evaluation of nutritional adequacy for one of one sampled resident (Resident 31) with a lacto-vegetarian preference to meet Resident 31's choices and special dietary needs. A planned lacto-vegetarian menu was not prepared in advance to meet Resident 31's ordered textured diet of mechanical soft (M/S-foods that are soft and easy to chew and swallow) ground consistencies which resulted in whole blueberries with the skin on being served which was not allowed on a M/S diet. This failure resulted in Resident 31's special dietary needs to not be met and a variety of menu items to not be provided…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the Infection Preventionist (IP) failed to demonstrate competency to carry out the functions of the Infection Prevention and Control Program for the facility when: 1. The IP did not follow the facility's policy and procedure (P&P) titled, Monitoring Compliance with Infection Control for surveillance (monitoring) activities, collecting, analyzing, tracking and trending of data. This failure had the potential for facility to be unaware of outbreaks and transmission of infectious diseases. [reference F880] 2. Enhanced Barrier Precaution were not implemented in the facility. This failure had the potential to spread infections to residents, staff, and visitors. [reference F880] Findings: 1. During a concurrent interview and record review on 3/5/25 at 8:53 a.m. with IP, the facility's surveillance activities for infection control were reviewed. IP stated he only monitored hand hygiene which included hand washing and hand rub, and donning on and doffing of Personal…

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 pharmaceutical services to meet the needs of one of four residents (Resident 1) when the facility did not provide a prescribed dose of Insulin Glargine (a medication to control blood sugar) and three prescribed doses of Potassium (a supplement for the prevention of kidney stones - a small, hard deposit that forms in the kidneys and is often painful when passed) for one of three sampled residents (Resident 1). These failures had the potential for Resident 1 to experience adverse health outcomes. Findings: During a review of Resident 1's Physician Orders , dated 1/1/25-1/31/25, the Physician Orders indicated Resident 1 was admitted to the facility on [DATE], had diagnoses including diabetes mellitus (a condition affecting blood sugar levels). The Physician Orders indicated the following medication orders: a) 1/24/25 (Insulin Glargine) BASAGLAR KWIKPEN.50 units subcutaneous TWICE DAILY AT 0900 & 2200 b) 5/2/24 (Potassium Citrate) POTASSIUM CITRATE…

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 (P&P) on recording and investigating grievances or complaints for one of three sampled residents (Resident 1) when Resident 1's grievance reports were not resolved, and Resident 1 was not informed of the findings of the investigation, as well as any corrective actions recommended. This failure had the potential to result in Resident 1 to develop adverse health outcomes from potentially experiencing repeated concerns from unresolved grievances. Findings: During a review of Resident 1's Record of admission (ROA), dated 4/20/23, the ROA indicated, Admitting/Subsequent Diagnoses. Type 2 diabetes mellitus (a disease that occurs when the body does not use insulin [a hormone or medication that lowers blood sugar] properly, resulting in high blood sugar). During an interview on 12/18/24 at 11:14 a.m. with Resident 1, Resident 1 stated she had filed multiple grievances. Resident 1 stated she had not been informed of the findings, and the facility's corrective actions for some of her grievances.…

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 (P&P) on administering medications for one of three sampled residents (Resident 1) when Resident 1's two insulin medications were not administered in a timely manner. This failure had the potential to result in Resident 1 to develop adverse health outcomes. Findings: During a review of Resident 1's Record of admission (ROA), dated 4/20/23, the ROA indicated, Admitting/Subsequent Diagnoses. Type 2 diabetes mellitus (a disease that occurs when the body does not use insulin [a hormone or medication that lowers blood sugar] properly, resulting in high blood sugar). During an interview on 12/18/24 at 11:14 a.m. with Resident 1, Resident 1 stated she has been getting her insulin more than an hour too late or too early. Resident 1 stated, It was making me anxious and nervous. I had shortness of breath. I was shaky. During a concurrent interview and record review on 12/18/24 at 2:32 p.m. with Director of Nursing (DON), Resident 1's Medication Administration Record (MAR), dated December 2024 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 interview and record review, the facility failed to provide reasonable accommodations for two of three sampled resident (Resident 1 and Resident 2). This failure had the potential for delay in care. Findings: During an interview on 10/14/24 at 11:37 a.m. with Resident 2, Resident 2 stated call lights take 20 minutes to be answered sometimes. Resident 2 stated the wait time was not acceptable. Resident 2 stated what if there was an emergency. During a review of Resident 2's Minimum Data Set, (MDS - an assessment tool) dated 10/19/24, the MDS indicated, Resident 2's BIMS (Brief Interview for Mental Status) score was 15 (a score of 13 to 15 points indicates the resident has cognitive intactness). During an interview on 10/14/24 at 11:37 a.m. with Resident 1, Resident 1 stated the facility had lots of call offs recently. Resident 1 stated one day (no date given) there was an issue where she waited 2 hours in a wet brief. Resident 1 stated, I had to lay in my mess for two hours to be change. Resident 1 stated, Makes you fell less than human. During a review of Resident 1's MDS,…

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 interview and record review, the facility failed to ensure medication were administered as ordered for one of three sampled residents (Resident 1). This failure had the potential for Resident 1 to have adverse outcomes. Findings: During an interview on 10/14/24 at 11:37 a.m. with Resident 1, Resident 1 stated she was sent to an appointment out of town (no date given) with an insulin (medication used to treat diabetes [chronic disease that occurs when the body does not produce enough insulin or does not use insulin properly resulting in high blood sugar levels]) pen but no needle. Resident 1 stated she did not receive insulin before lunch recently (no date given). Resident 1 stated she was supposed to get her Ozempic (medication used to treat diabetes) on Friday but did not get it until Saturday. Resident 1 stated Ozempic should be given timely so it will be effective. During an interview on 10/14/24 at 12:46 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated medications can be administered one hour before and one hour after scheduled time frame. During a concurrent…

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

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), mail was delivered unopened. This failure resulted in violation of Resident 1's resident rights and privacy. Findings: During an interview on 5/14/24 at 10:24 a.m. with Resident 1, Resident 1 stated Administrative Service Manager in Training (ASM) handed her a letter from her insurance company and the letter was addressed to her, with her name on it. Resident 1 stated the letter was opened without an envelope. Resident 1 stated she asked ASM who opened her mail, she stated ASM did not respond. During a review of Resident 1's Interdisciplinary Progress Note, (IDTPN) dated 5/7/24 at 3:46 p.m. the IDTPN indicated, In the office this writer [ASM] had and [insurance] letter for [Resident 1] which was unopened. In order to assist, this writer [ASM] assumed this must be the letter [Resident 1] was talking about as the resident only showered [sic] an email version, and [ASM] opened the letter. During an interview on 5/14/24 at 1:11 p.m. with ASM, ASM stated Resident 1 asked him…

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 three sampled residents (Resident 1) grievances were resolved. This failure had the potential for negative psychosocial outcomes. Findings: During an interview on 5/14/24 at 10:24 a.m. with Resident 1, Resident 1 she stated she filed grievances, but the facility did not resolve her grievances. During a concurrent interview and record review on 5/14/24 at 3:13 p.m. with Administrative Service Manager in Training (ASM), ASM reviewed Resident 1's Resident/Family Concern/Grievance Report, (RFCGR) dated 4/22/24, 5/1/24. 5/4/24. ASM confirmed RFCGR were not completed (no follow up, no resolution, not signed off by administration, and the forms were not signed by Resident 1 concluding the grievances were resolved). ASM confirmed the findings and stated the resident did not sign the form to prove the grievances had been resolved. During a review of the facility's policy and procedure (P&P) titled, Grievances/Complaints, Filing, revised April 2017, the P&P indicated, The administrator and staff will make prompt…

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

Based on interview and record review, the facility failed to ensure adequate supplies were available for two of three sampled residents (Resident 1 and Resident 2). This failure had the potential for Resident 1 and Resident 2 to have unmet care needs and discomfort. Findings: During an interview on 5/14/24 at 10:24 a.m. with Resident 1, Resident 1 stated the facility runs out of chux (underpads) and wipes, she stated they (facility) ran out last night. Resident 1 stated it happens usually at night. During an interview on 5/14/24 at 11:13 a.m. with Resident 2, Resident 2 stated the facility run out of large briefs and chux about twice a month. Resident 2 stated when they run out the staff will put a larger brief or a smaller brief on him. Resident 2 stated When the staff puts a larger brief it was not tight enough to hold the liquid in and cause leaks and when the staff puts the smaller one on it is too tight and uncomfortable. Resident 2 stated the facility should not run out briefs are a predictable item, they (facility) should learn for their mistakes. During an interview 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.

Based on interview and record review, the facility failed to ensure care plan was implemented for one of three sampled residents (Resident 1) when the behaviors were not monitored hourly. This failure had the potential for Resident 1 to have increased behavioral changes due to unmonitored behaviors and delayed psychosocial interventions. Findings: During a review of Resident 1's SW (Social Worker) Note, dated 4/24/24, the SW Note indicated Resident 1 stated he will kill Licensed Vocational Nurse (LVN) 1. During a review of Resident 1's Care Plan (CP), dated 4/24/24, the CP indicated, Resident verbalized inappropriate statements including threat of life and safety of treatment nurse . Interventions .hourly rounding for location behavior and activity. During a review of Resident 1's Active Orders Report (AOR), dated 4/25/24, the AOR indicated, Hourly Rounding Monitor for location, behavior and activity. Document in comment section every hour. During a review of Resident 1's Administration Order Text (AOT), dated 4/25/24 and 4/26/24, the AOT indicated there were no documentation of…

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

Based on observation, interview, and record review, the facility failed to monitor efficacy of the bed alarm to ensure it (bed alarm) was functioning for one of four sampled residents (Resident 1). This failure had the potential to result in Resident 1 having an unwitnessed fall and sustaining an injury. Findings: During an observation on 4/8/24 at 7:46 a.m. in Resident 1's room. Resident 1 was lying in bed with her eyes closed. Resident 1 had bilateral half upper side rails up, fall mats on both sides of bed, call light within reach, and room was free of clutter. Resident 1 opened her eyes slightly and then closed them again when being spoken to. Resident 1 did not say anything. During a review of Resident 1's Post Fall Review/Fall Risk Assessment (PFRFRA), dated 3/17/24, the PFRFRA indicated, 3/17/24 at 18:55 [6:55 p.m.] staff were alerted by tx [treatment] nurse [LVN 3]. Upon assessment resident [1] was laying on fall mat on side of bed closet to window; resident [1] was seated on bottom with knees bent. Resident [1] states she fell. Unwitnessed. Outcome: Major Injury. Transverse…

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 develop and implement an action plan in the facility's Quality Assessment and Performance Improvement (QAPI), when the Pharmacist had identified significant medication errors during his monthly Medication Regiment Review (MRR) for 13 of 49 sampled residents (Resident 13, Resident 14, Resident 24, Resident 25, Resident 31, Resident 37, Resident 38, Resident 45, Resident 46, Resident 47, Resident 48, Resident 49, and Resident 51). This failure resulted in residents not receiving accurate medications and had the potential to cause adverse reactions from medications. Findings: During a concurrent interview and record review on 3/14/24 at 8:31 a.m. with Director of Nursing (DON), the facility's Consultant Pharmacist's Medication Regimen Review (CPMRR), book dated 5/2023, 6/2023, 7/2023, 11/2023, and 12/2023 were reviewed. The CPMRR indicated the following medication errors per month: 5/20/2023, 3 errors Resident 48 - Order: Novolin R (insulin - control blood sugar) 100 u/ml (unit/milliliter) per low dose sliding scale: BS…

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 five of 49 sampled residents (Resident 15, Resident 32, Resident 108, Resident 259, and Resident 260) were provided a copy of the facility's admission policies and procedures (P&P) upon admission. This failure had the potential for residents to be unaware of the facilities policies, financial obligations, and their rights. Findings: During an interview on 3/11/24 at 3:54 p.m. with Social Service Designee (SSD), SSD stated she is responsible for completing admission packets with resident and family upon admission. SSD stated the Administrator would fill out the packet but she would review it with the Resident and family and obtain their signatures. During a concurrent interview and record review on 3/12/24 at 8:15 a.m. with SSD, the facility's New Admissions in the Last 30 days who are still residing in the facility was reviewed. SSD stated Resident 15 was admitted on [DATE] and the California Standard admission Agreement for Skilled Nursing…

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 49 sampled residents (Resident 37) reported loss of personal belongings was investigated. This failure resulted in not recovering Resident 37's lost of personal belongings and had the potential for the recurrence of lost personal belongings of other residents. Findings: During an interview on 3/12/24 at 10:53 a.m. with Resident 37, Resident 37 stated he had reported a loss of clothing (two shirts and two pajama pants) to social services over four months ago and the issue had not yet been resolved. During an interview on 3/13/24 at 1:40 p.m. with Social Service Designee (SSD), SSD stated, I am aware of the lost personal belongings, some shirts [for Resident 37]. SSD stated Social Service Manager (SSM) and I handle the grievance process together and the SSM was handling this issue with Resident 37. During an interview on 3/13/24 at 1:53 p.m. with SSM, SSM stated he recalled Resident 37 verbally telling him about his loss of two shirts and two pajama bottoms around December 23, 2023. SSM stated it slipped his…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of 49 sampled residents (Resident 22 and Resident 309) were provided assistance with ADLs (ADL-tasks of everyday life including eating, dressing, getting in or out of a bed or chair, and bathing) when: 1. Resident 22 was not provided assistance with the use of her hearing aides. This failure resulted in Resident 22 not being able to communicate with the staff regarding her needs. 2. Resident 309 did not receive Restorative Nursing Assistant (RNA- nursing interventions that promote the ability to adapt and adjust to living as independently and safely as possible) treatments for three days. This failure had the potential for Resident 309 to have a decline in his ability to perform activities of daily living. Findings: 1. During a concurrent observation and interview on 3/11/24 at 10:37 a.m. in Resident 22's room, Resident 22 touched inside her ears and stated she was hard of hearing and wears hearing aides, and did not have them…

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 infection control measures were done for two of 49 sampled residents (Resident 10 and Resident 32) when: 1. Certified Nursing Assistant (CNA) 2 did not assists Resident 10 with hand hygiene before eating. This failure had the potential to adversely affect Resident 10's health. 2. Licensed Vocational Nurse (LVN) did not wash her hands before and after wound treatment to Resident 32's wound in the coccyx (tailbone). This failure had the potential to result in infection of Resident 32's wound in the coccyx. Findings: 1. During a concurrent observation and interview on 3/11/24 at 12:31 p.m. with Certified Nursing Assistant (CNA) 2 in Resident 10's room, CNA 2 delivered Resident 10's lunch tray without providing hand hygiene to Resident 10 who eats with her hands. CNA 2 stated she should have provided hand hygiene for Resident 10 before delivering her lunch tray. During an interview on 3/11/24 at 12:58 p.m. with Resident 10, Resident 10 stated she had not had her hands washed before her lunch tray 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 interview and record review the facility failed to prevent abuse for one of three sampled residents (Resident 1). This failure had the potential for negative consequences including physical harm and/or emotional harm for Resident 1 and other facility residents. Findings: During an interview on 10/17/23 at 12:05 p.m. with Minimum Data Set Nurse (MDSN), MDSN stated on 10/8/23 Resident 1 was found by Certified Nursing Assistant (CNA) 1 with her legs restrained by a sheet. MDSN stated an investigation was started but the facility was unable to determine who tied Resident 1's legs together. MDSN stated Resident 1 is cognitively (mental process that deals with thoughts, memory, skills) impaired. MDSN stated Resident 1 repeats words but does not remember much else. During a review of Resident 1's Brief Interview for Mental Status (BIMS), dated 9/14/23, the BIMS indicated, Resident 1 had a score of 6 (severely cognitively impaired). During a review of Resident 1's PHYSICIANS ORDERS (PO), dated 10/1/23, the PO indicated, there were no orders for the facility to use any type 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 implement its policy and procedure (P&P) regarding employee abuse training for one of three sampled Certified Nursing Assistants (CNA) 2. This failure had the potential for CNA 1 to not have knowledge on how to prevent, report and/or identify abuse in the facility. Findings: During a concurrent interview and record review on 10/17/23 at 12:55 p.m. with Director of Staff Development (DSD), the facility abuse education for staff ([NAME]) was reviewed. The [NAME] indicated CNA 2 had not received abuse training since 8/29/22. DSD stated abuse education is to be done minimally at least once a year or four hours of abuse training every two years for every staff member in the facility. DSD stated CNA 2 was out of compliance with her abuse training. During a review of the facility ' s policy and procedure (P&P) titled, IN-SERVICE TRAINING PROGRAM FOR CERTIFIED NURSE ASSISTANTS, not dated, the P&P indicated, SPECIAL NOTE: Each facility is required to complete…

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

Based on interview and record review, the facility failed to notify one of three sampled residents (Resident 2) resident's representative (RR) regarding a change of condition. This failure resulted in Resident 2's RR to be unaware of Resident 2's fall incident. Findings: During a concurrent interview and record review on 9/13/23, at 12:24 p.m. with Licensed Vocational Nurse (LVN 1), LVN 1 reviewed Resident 2's Post Fall Risk Review/Fall Risk Assessment v1.4 Change in Condition, (COC) dated 9/11/23, LVN 1 confirmed Resident 2 had an unwitnessed fall and undergone neurological checks (an exam evaluates brain and nervous system functioning). LVN 1 confirmed Resident 2's RR was not notified of Resident 2's fall incident. LVN 1 reviewed Resident 2's Interdisciplinary Progress Notes, (IPN) dated 9/11/23 to 9/13/23. LVN 1 confirmed Resident 2's RR was not notified. During a review of Resident 2's Admissions Record (AR), the AR indicated, Resident 2 had a RR and a POA (power of attorney- a legal document that allows someone else to act on your behalf). During a review of Resident 2'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 record review, the facility failed to implement the plan of care for one of three sampled residents (Resident 1). This failure had the potential for accidents and injuries. Findings: During a review of Resident 1 Post Fall Risk Review/Fall Risk Assessment v1.4 Change in Condition, (COC) dated 8/28/23, the COC indicated Resident 1 had a witnessed fall. The COC indicated, Recommendations- . Other: low bed with fall mats During a concurrent observation and interview on 9/13/23, at 11:24 a.m. with Certified Nursing Assistant (CNA 1), in Resident 1's room. CNA 1 confirmed Resident 1 was lying in bed and two mats were next to Resident 1's bed against the wall. CNA 1 stated The mats should be at bedside when (Resident 1) is in bed. During a concurrent interview and record review on 9/13/23, at 2:16 p.m. with Administrator, Administrator reviewed Resident 1's Plan of Care, (POC) with the focus on risk for falls, the POC indicated, Bilateral Fall mats effective date 8/31/23 . Administrator stated the plan of care should be resident specific documented 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: 1. Complete a Neurological Record (NR) for one of three sampled residents (Resident 1) after an unwitnessed fall. This failure had the potential for Resident 1 to experience unnoticed neurological deficits. 2. Ensure Fall Prevention, procedures were followed for one of three sampled residents (Resident 3). This failure had the potential to result in serious injuries. Findings: 1. During a review of Resident 1's Post Fall Risk Review/Fall Risk Assessment v1.4 Change in Condition, (COC) dated 8/25/23, the COC indicated Resident 1 had an unwitnessed fall. During a concurrent interview and record review on 10/2/23, at 3:45 p.m. with Quality Assurance Nurse (QAN), QAN stated the NR should be initiated immediately after an unwitnessed fall incident and end after 72 hours per facility protocol. QAN reviewed Resident's NR and confirmed Resident 1's NR, initiated on 8/25/23 at 9 p.m. was not completed. QAN reviewed Resident 1's medical record and confirmed…

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.