Riverbank Post-Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to meet professional standards of practice for two of five sampled residents (Resident 1 and Resident 4) when the physician and Resident Responsible Party (RP) were not notified of Resident 1 and Resident 4's refusal of care with having their nails trimmed. Findings:During a concurrent observation and interview on 9/10/25 at 11:26 a.m. with Certified Nursing Assistant (CNA) 1 in the hallway outside Resident (R) 4's room, R 4 was non-verbal and observed wearing a gown, laying in a geriatric chair (Geri-chair - a semi-specialized seating for older adults that achieves a reclined position and elevated leg rest) in the hallway with his left foot uncovered. R 4's left foot toenails were observed to be long, yellow, thick and jagged with dark crusted substance under his left big toenail. CNA 1 stated if a resident was not diabetic (when the blood sugar levels in the body are too high), the nurses trimmed the resident's nails. CNA 1 stated the CNAs…

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 foot care and treatment, in accordance with professional standards of practice for two of four sampled residents (Resident 1 and Resident 4) when Resident 1 and Resident 4 had long, overgrown toenails. This failure had the potential to result in Resident 1 and Resident 4 cutting their skin with their long toenails, leading to poor wound healing, infection, and hospitalization. Findings:During a concurrent observation and interview on 9/10/25 at 11:26 a.m. with Certified Nursing Assistant (CNA) 1 in the hallway outside Resident (R) 4's room, R 4 was non-verbal and observed wearing a gown, laying in a geriatric chair (Geri-chair - a semi-specialized seating for older adults that achieves a reclined position and elevated leg rest) in the hallway with his left foot uncovered. R 4's left foot toenails were observed to be long, yellow, thick and jagged with dark crusted substance under his left big toenail. CNA 1 stated if a resident 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 notify the physician that 1 (Resident #6) of 1 sampled resident reviewed for dialysis did not receive their ordered medications when they were out of the facility at dialysis three days each week. Findings included: An admission Record revealed the facility admitted Resident #6 on 04/06/2024. According to the admission Record, the resident had a medical history to include diagnoses of acute pulmonary embolism, dependence of renal dialysis, major depressive disorder, hypotension, chronic embolism and thrombosis of left lower extremity, and chronic kidney disease. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/30/2024, revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #6's Care Plan Report included a focus area initiated 12/29/2023, that indicated the resident needed dialysis related to a diagnosis of end stage renal disease. Interventions indicated the resident's dialysis days were Mondays,…

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, record review, and facility policy review, the facility failed to ensure a new level I preadmission screening and resident review (PASARR) was completed for 2 (Resident #53 and Resident #75) of 2 sampled residents reviewed for PASARR, who remained in the facility after 30 days. Findings included: A facility policy, titled, admission Criteria, revised 03/2019, indicated, 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. 1. An admission Record indicated the facility admitted Resident #53 on 09/12/2024. According to the admission Record, the resident had a medical history that included diagnoses of borderline personality disorder and bipolar disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/04/2025, revealed Resident #53 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. Resident #53's Care…

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

Based on interview, record review, and facility policy review, the facility failed to ensure a resident's care plan reflected the resident's refusal to sign the smoking policy and interventions for staff to obtain a cigarette lighter from the resident for 1 (Resident #37) of 1 sampled resident reviewed for smoking. Findings included: A facility policy titled, Care Plans, Comprehensive Person-Centered, revised 03/2022, indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The policy specified, 9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 10. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. 11. Assessments of residents are ongoing and care plans are revised as information…

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

Based on observation, interview, record review, and facility policy review, the facility failed to maintain a medication error rate of 5 percent (%) or less. There were 2 errors out of 26 opportunities, which resulted in a medication error rate of 7.69% for 1 (Resident #12) of 8 residents observed for medication administration. Findings included: A facility policy, titled, Administering Medications, revised 04/2019, indicated, 4. Medications are administered in accordance with prescriber orders, including any required time frame. An admission Record indicated the facility admitted Resident #12 on 11/19/2024. According to the admission Record, the resident had a medical history that included diagnoses of muscle weakness and age-related osteoporosis. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/05/2025, revealed Resident #12 had a Brief Interview for Mental Status (BIMS) of 9, which indicated the resident had moderate cognitive impairment. Resident #12's Order Summary Report for active orders as of 03/13/2025, revealed an order dated 11/19/2024, for…

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

Based on interview, record review, and facility policy review, the facility failed to ensure 1 (Resident #6) of 19 sampled residents did not experience significant medication errors. Specifically, Resident #6 did not receive their antidepressant, diuretic, anticoagulant, and blood pressure medications as ordered by the physician three days each week when the resident was out of the facility at dialysis. Findings included: A facility policy, titled, Administering Medications, revised 04/2019, indicated, 4. Medications are administered in accordance with prescriber orders, including any required time frame. An admission Record revealed the facility admitted Resident #6 on 04/06/2024. According to the admission Record, the resident had a medical history to include diagnoses of acute pulmonary embolism, dependence of renal dialysis, major depressive disorder, hypotension, chronic embolism and thrombosis of left lower extremity, and chronic kidney disease. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/30/2024, revealed Resident #6 had a Brief Interview…

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 six sampled residents (Resident 1), was free from verbal abuse when his roommate Resident 2, verbally assaulted him with a racial epithet on multiple occasions. This failure resulted in Resident 1 being a victim of continued racially based verbal abuse. Findings: During an interview on 6/20/24, at 3 PM, with Resident 1, Resident 1 stated his roommate (Resident 2) was continuously cussing at me and using vulgar language. Resident 1 stated he had recently informed the facility's Social Services Department of this, and they told him Resident 2 would be moved to a different room on 6/17/24. Resident 1 stated that his roommate had yet not been moved as of 6/20/24 and was given no explanation why. During an interview on 6/21/24, at 4 PM, with Resident 1, Resident 1 stated Resident 2 had still not been moved out to a different room. Resident 1 stated nobody had come to him to address the situation despite his complaints. Resident 1 stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to investigate an allegation of verbal abuse for one of six sampled residents (Resident 1), when Resident 1 had complained to facility staff that his roommate, Resident 2, was continuously calling him a racial epithet. This failure resulted in Resident 1 being subjected to further verbal abuse from Resident 1. [Cross Reference F600]. Findings: During an interview on 6/20/24, at 3 PM, with Resident 1, Resident 1 stated his roommate (Resident 2) was continuously cussing at me and using vulgar language. Resident 1 stated he had recently informed the facility's Social Services Department of this. During an interview on 6/21/24, at 4 PM, with Resident 1, Resident 1 stated Resident 2 calls him [n-word]. Resident 1 stated that for one example, when Resident 2 turned his music on at 4 AM, he asked Resident 2 to turn it down and Resident 2 responded by saying, Shut up, [n-word]. Resident 1 stated, That's not OK. I pay money to be here, I should not be spoken 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 interview and record review, the facility failed to: 1. Report an allegation of verbal abuse to the California Department of Public Health for one of six sampled residents (Resident 1) when Resident 2 called him a racial epithet on multiple occasions, and 2. The facility did not report the results of the abuse investigation to the California Department of Public Health within five days. These failures resulted in the verbal abuse of Resident 1 to go uninvestigated, subjecting Resident 1 to continued verbal abuse. Findings: During an interview on 6/20/24, at 3 PM, with Resident 1, Resident 1 stated his roommate (Resident 2) was continuously cussing at me and using vulgar language. Resident 1 stated he had recently informed the facility's Social Services Department of this. During an interview on 6/21/24, at 4 PM, with Resident 1, Resident 1 stated Resident 2 calls him [n-word]. Resident 1 stated that for one example, when Resident 2 turned his music on at 4 AM, he asked Resident 2 to turn it down 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 develop a safe and effective discharge plan for one of three sampled residents (Resident 1) when Resident 1 was discharged to an assisted living facility (ALF-type of residence for older adults who need daily care) without an interdisciplinary team (IDT-variety of medical professionals who plan and coordinate patient care) meeting to develop discharge goals and post discharge care needs involving the resident's Public Guardian Conservator (PGC-a resident representative responsible for managing financial and medical decisions for a person who is incapacitated [physically or mentally unable to manage one's affairs]), and did not review a post discharge plan with the PGC prior to discharge according to the facility's policy and procedure. This failure placed Resident 1 at risk for his medical needs to go unmet after discharge. Findings: During a review of Resident 1's Order Summary Report, (OSR) dated 12/6/2023, the OSR indicated, . order to d/c…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain a safe environment for two of six sampled residents (Residents 1 and 2) with a Wander guard bracelet (system which triggers an alarm to alert staff when a resident at high risk for elopement [when a person leaves a safe area unattended and unsupervised] is close to an exit door) when Residents 1 and 2 did not have a Wander guard bracelet on and the Licensed Nurses (LN) failed to check the Wander guard for placement and functionality every shift according to the physician ' s order. This failure resulted in Resident 1 leaving the facility in his wheelchair, crossing a busy highway unattended and without staff knowledge on 4/28/24, which placed him at risk for serious injury and Resident 2 was at risk for elopement. (cross reference F921) Findings: During a review of Resident 1 ' s Nurses Notes, dated 4/28/24 at 7:14 a.m., the notes indicated, . 0635 [6:35 a.m.] Patient was seen wheeling himself down the street away from the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe and functional environment when one of four exit door alarms tested did not function (to alert staff) properly. This failure had the potential for residents to leave the facility undetected by staff, which placed residents at risk for serious injury, accidents and/or death. (cross reference F689) Findings: During a concurrent interview and record review on 5/15/24 at 1:15 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 1's Order Summary Report, (OSR) dated 5/2024 was reviewed. The OSR indicated, . Monitor Placement and Function of SMART Wander-Guard to W/C [wheelchair] Qshift [every shift] . Order date 5/21/2023 . LVN 1 stated Resident 1 had eloped (left the facility without staff knowledge or supervision) from the facility on 4/28/24. LVN 1 stated Resident 1 was known to have exit seeking (wandering and intentionally looking for a way out) behaviors but the Wander guard or exit door alarms should have alerted staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an effective infection control program for two of six sampled residents (Residents 4 and 6) when the Treatment Nurse (TN) failed to follow infection control precautions during wound care. These failures placed Residents 4 and 6 at risk for wound infections. Findings: During a review of Resident 4 ' s admission Record (AR-a document with person identifiable and medical information), undated, the AR indicated, Resident 4 was admitted to the facility on [DATE] with diagnoses which included neuromuscular dysfunction of bladder (lack of bladder control caused by nervous system condition), pressure ulcer (injury to the skin and tissue below the skin due to long periods of pressure) of sacral region (bottom of the spine) stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle), pressure ulcer of left hip stage 3 (full thickness tissue loss without exposed bone, tendon, or muscle) and paraplegia (paralysis of the legs).…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a person-centered comprehensive care plan for one of six sampled residents (Resident 1) when Resident 1 did not have a care plan with measurable goals and interventions after testing positive for Coronavirus disease 2019 (COVID-19-a highly contagious infectious disease caused by a virus from respiratory droplets that can spread from person to person) on 11/10/23 and Licensed Nurses did not develop a care plan for oxygen therapy since her admission to the facility on [DATE]. These failures had the potential for Resident 1's COVID-19 and oxygen therapy care needs to go unmet. Findings: During a review of Resident 1's admission Record (AR-document containing resident demographic information and medical diagnosis) undated, the admission record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnosis included type 2 diabetes mellitus (high levels of sugar in the blood), atrial fibrillation (a fib-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 meet professional standards of practice for one of six sampled residents (Resident 1) when Licensed Vocational Nurse (LVN) 2 did not follow professional standards for the administration of oxygen (O2- an odorless gas that is present in the air and necessary to maintain life) on 11/14/23 when she administered oxygen to Resident 1 with a non-rebreather mask (a special mask placed over the nose and mouth to provide oxygen in emergencies) without a physician's order. This failure placed Resident 1 at risk for suffocation (die from being unable to breathe) from improper usage of a non-rebreather mask. Findings: During a review of Resident 1's admission Record (AR-document containing resident demographic information and medical diagnosis) undated, the admission record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnosis included type 2 diabetes mellitus (high levels of sugar in the blood), atrial fibrillation (a fib-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.

Based on observation, interview and record review, the facility failed to maintain patient care equipment in safe operating condition when: 1. Shower room was not functional for over a month, for residents requiring a shower gurney (shower bed) for three of three sampled residents (Resident 1, 2 and 3) This failure resulted in Residents 1, 2, and 3 not receiving a shower for over a month. 2. Call lights were not operational for two of three sampled residents (Resident 2 and 3). This failure resulteds in Resident 2 and 3 not being able to use the call light to ask for assistance when needed and in the event of an emergent situation. Findings: 1. During an interview on 11/29/23 at 10:14 a.m. with Resident 1, Resident 1 stated she was receiving bed baths for a month. Resident 1 stated she wanted to take a shower because she enjoyed when the warm water ran down her body. Resident 1 stated she liked showers because it made her feel clean. During a review of Resident 1 ' s Minimum Data Set Assessment (MDS - a resident assessment tool used to identify resident cognitive and physical…

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 residents were treated with respect and dignity consistent with enhancing each resident's quality of life and recognizing each resident's individuality for three of 10 sampled residents (Residents 52, 59 and 64) when the facility failed to provide group activities and communal dining for 18 days. This failure resulted in the facility not promoting the rights of Residents 52, 59 and 64 to a dignified and respectful existence and had the potential to compromise their health and well-being. Findings: During an observation on 9/19/23, at 9:40 a.m., in the facility dining room, two male construction workers were observed moving lumber materials and construction tools from the east side to the west side of the dining room area. New wood framed walls with taped dry wall and Light Emitting Diode (LED - a type of light that is more efficient than incandescent light bulbs) lighting being installed were observed. A sign was posted outside the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide an ongoing activity program to meet the needs and interests for three of 10 sampled residents (Residents 52, 59 and 64) when Residents 52, 59 and 64 were not provided their activities of interests and had no communal dining for 18 days due to the ongoing construction in the facility's dining room. This failure resulted in Residents 52, 59 and 64's activities needs to go unmet. Findings: During an observation on 9/19/23, at 9:40 a.m., in the facility dining room, two male construction workers were observed moving lumber materials and construction tools from the east side to the west side of the dining room area. New wood framed walls with taped dry wall and Light Emitting Diode (LED - a type of light that is more efficient than incandescent light bulbs) lighting being installed were observed. A sign was posted outside the dining room indicating the dining room was closed and undergoing renovation. During a concurrent observation…

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, staff interview, and record review, the facility failed to ensure menus were followed by [NAME] 2 (CK) 2 during the lunch meal preparation on 9/20/23 for 83 of 91 residents who received food from the kitchen when the lunch menu had an unplanned vegetable substitute. This failure had the potential for residents to receive inadequate nutrients in their meals. Findings: During an observation and record review, of the lunch meal on 9/20/23, a cooked vegetable mixture of cauliflower, carrots, and zucchini was served instead of the planned vegetable mixture on the menu. The menu for the noon indicated, Tandoori Chicken, [NAME] Rice, Stir Fried Vegetables, Frosted Pumpkin Cake. Vegetables, Stir Fry were to be used. The recipe for Vegetables, Stir Fry indicated, Carrots, fresh pepper, green fresh, celery, fresh onions, fresh, mushrooms, fresh, oil, vegetable. The recipe for the sauce indicated, Soy sauce, low sodium, garlic powder, ginger, ground, water, cornstarch. During a concurrent interview and record review, on 9/21/23 at 10:45 a.m., with CK 2, CK 2 reviewed the…

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

Based on observation, interview and record review, the facility failed to ensure eight of 45 sampled residents (Residents 9, 16, 46, 70, 2, 27, 51 and 66) received pureed foods that were prepared by methods to conserve the nutritive value of food when on 9/20/2023, [NAME] 2 (CK) 2 did not follow the pureed consistency for the preparation of lunch meal in accordance with the pureed policies and procedures. This failure placed residents receiving a pureed diet at risk for compromised nutritional status. Findings: During a concurrent food preparation observation and interview, on 9/20/23 at 9:25 a.m., with [NAME] CK 2, Certified Dietary Manager (CDM) and the Dietetic Services Supervisor (DSS), CK 2 placed several pieces of baked chicken in a large blender. A two-quart saucepan filled with gravy had been prepared prior to this observation and appeared of thin consistency. CK 2 stated she had made gravy and did not measure the water or chicken gravy mix powder. CK 2 stated she thought she used eight ounces of water and about half of the gravy mix. CK 2 stated, The whole bag has to be for…

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

Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food safety when: 1. Food particles that were brownish in color lay on the bottom shelf of the stand-up freezer and two open, uncovered plastic bins which held serving/cooking utensils were under the sink area by the stove. 2. A scoop was left inside the flour bin. 3. Two-five-pound bags of cake mix had sticky substance in between the bags. 4. A soiled blanket with black and brown discoloration was on the floor at the storage room where the emergency water supplies were located. 5. Water pitchers were stacked and stored in a cupboard and there was moisture in between the water pitchers. 6. Two green buckets with gray colored water and had soiled cleaning cloths with brownish discoloration sat on the floor under the dishwasher. 7. Three frying pans which hung on the steam table had chips and scratches on its non-stick coating. These failures placed residents at risk for foodborne illnesses (illness caused by consuming contaminated food). Findings: 1.…

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

Based on observation, interview, and record review, the facility failed to dispose garbage under sanitary conditions when one of three garbage containers in the kitchen was uncovered. This failure had the potential to attract rodents, insects and flies and spread infection which place residents at risk of foodborne illness. Findings: During an observation on 9/21/23 at 1:20 p.m., there were three large dumpsters at the back side of the facility. One of three large dumpsters was open without the lids to cover its contents. During a concurrent observation and interview, on 9/22/23 at 9: 40 a.m. with the Dietetic Services Supervisor (DSS), on tour outside to the trash collection area, it was noted that one of the three large trash dumpsters was open with a lid flopped over the side. The DSS stated, Everybody goes out there. [My staff] close it up but anyone else can access these dumpsters. We are not the only staff using the dumpsters for trash. The DSS stated if the lids were not closed, it could attract pests and flies and potentially cause cross-contamination with 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow its Hospice (care that focuses on the quality of life for people who are experiencing an advanced, life-limiting illness) policy and procedures for five of five sampled residents (Residents 9, 29, 34, 72, and 87) when the facility failed to ensure that Hospice personnel caring for residents under Hospice services were provided orientation to the facility's policies and procedures (P&P). This failure had the potential to place Residents 9, 29, 34, 72, and 87 at risk of not receiving appropriate medical, physical, psychosocial, and spiritual support to manage symptoms associated with terminal illness. Findings: During an interview on 9/19/23, at 11:38 a.m., with Hospice Licensed Vocational Nurse (HLVN), in Station A hallway, HLVN stated she was the assigned Hospice Nurse for two hospice residents, Resident 72 and Resident 87. HLVN stated she visited the facility multiple times for the current month and conducted Resident 72 and Resident 87's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. During a review of Resident 3's admission record, the admission record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD- lung diseases that make it hard to breathe and get worse over time). During a concurrent observation and interview, on 9/19/23 at 10:25 a.m. with Certified Nursing Assistant (CNA) 1 in Resident 3's room, Resident 3's foley catheter bag was placed inside a privacy cover (a bag which discreetly conceals a urine drainage bag from public view) and was observed on the floor underneath Resident 3's bed. CNA 1 stated, .Yes, it [foley catheter bag] is on the floor . and stated the foley catheter bag should not be on the floor. During an interview on 9/21/23 at 9:49 a.m. with the Infection Preventionist (IP), the IP stated, the foley catheter bag should not be on the floor to prevent possible infections to Resident 3. The IP stated the expectation was not to have the foley catheter bag dragging or just on the floor.…

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 properly maintain the ice machine in safe operating condition when the ice machine had been out of service multiple times since May 2023 and had been shut down for use beginning the week of 9/10/2023 due to the ongoing construction project in the dining room. This failure placed residents at risk of developing food borne illness (illness caused by consuming contaminated food) and had the potential to compromise availability of ice for residents. Findings: During a concurrent observation and interview, on 9/20/23 at 8:55 a.m. with the Certified Dietary Manager (CDM) and the Dietetic Services Supervisor (DSS), the ice machine in the corner of the large room next to the kitchen was marked with red tape and a sign which read Not working. The CDM stated the ice machine had been shut down last week due to the re-construction project in that room to prevent dust and contamination from getting into the machine. The DSS stated the staff had been buying bagged ice and stored it in the freezer downstairs. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure there was sufficient space to accommodate group activities and communal dining for five of 12 sampled residents (Residents 32, 43, 52, 59 and 64) when the facility's dining room/activities room was under renovation since September 5, 2023 to present. This failure resulted in Residents 32, 43, 52, 59 and 64 to not participate in group activities and communal dining for two weeks and placed residents at risk to feel isolated and depressed. Findings: During an observation on 9/19/23, at 9:40 a.m., in the facility dining room, two male construction workers were observed moving lumber materials and construction tools from the east side to the west side of the dining room area. New wood framed walls with taped dry wall and Light Emitting Diode (LED - a type of light that is more efficient than incandescent light bulbs) lighting being installed were observed. A sign was posted outside the dining room indicating the dining room was closed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment when: 1. The facility dining room was renovated without first notifying the California Department of Healthcare Access and Information (HCAI, a government agency for the State of California in charge of safety regulations for health care facilities, financial assistance to health care institutions, collecting healthcare data and more) and the California Department of Public Health (CDPH, a government agency for the State of California in charge of protecting the public's health and helps shape positive health outcomes for individuals, families and communities) and the facility did not obtain an alteration permit from HCAI. This failure placed residents and staff safety at risk for an unsafe and unsanitary environment which had the potential to result in electrocution, skin burns, ceiling and wall collapse. 2. Residents 3 and Resident 7's toilet was clogged and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to protect the personal privacy for one of 21 sampled residents (Resident 244) when the window in Resident 244's room overlooked the common smoking area and was not covered with a curtain or blinds. This failure violated Resident 244's right to privacy and confidentiality. Findings: During a record review of Resident 244's admission Record (AR-a document with personal identifiable and medical information), dated September 2023, the AR indicated Resident 244 was admitted to the facility on [DATE] diagnoses which included diabetes mellitus (a disease of inadequate control of blood levels of sugar), osteomyelitis (a serious infection of the bone) of the right ankle/foot, and heart disease. During a review of Resident 244's Minimum Data Set (MDS-a resident assessment tool used to identify resident cognitive [pertaining to reasoning memory and judgement] and physical functional level) assessment, dated 9/27/23, the MDS indicated Resident 244's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure services provided meet professional standards of practice for one of 32 sampled residents (Resident 294) when the facility failed to obtain a physician's order to remove the eight surgical staples (used to close incisions after surgery) on Resident 294's left forehead surgical incision (a cut made through the skin and soft tissue). This failure placed Resident 294 at high risk for infection and complications from a delay in suture removal. Findings: During a review of Resident 294's admission Record (AR, a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 9/20/23, the AR indicated, Resident 294 was admitted from an acute care hospital on 9/15/23 to the facility, whose diagnoses included Intracerebral Hemorrhage (stroke, bleeding between the brain tissue and skull), Respiratory Failure (a serious condition that makes it difficult to breathe), Dysphagia…

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 medications were stored and labeled in accordance with acceptable professional standards of practice for one of four sampled medication carts (Station B medication cart) when Resident 89's tiotropium bromide inhaler (a medication which is inhaled through the mouth to help people with damaged lungs breath better) did not have a resident identifier or label. This failure had the potential for the medication to be given to the incorrect resident which could cause adverse reactions (harmful unintended result caused by a medication) and or cross contamination (the physical movement or transfer of harmful bacteria from one person, object or place to another). Findings: During a record review of Resident 89's admission Record (AR-a document with personal identifiable and medical information), dated September 2023, the AR indicated Resident 89 was admitted to the facility on [DATE] diagnoses which included Chronic Obstructive Pulmonary…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain a comfortable and homelike environment for two of three sampled residents (Resident 66 and Resident 20) when: 1. The bottom part of the door had crusted and peeled paints. 2. There were eight holes in the wall near the television that was approximately one millimeter (mm- a unit of dry measurement) in length in Resident 66 and Resident 20's room. 3. The bathroom sink was loose and approximately 2.5 centimeters in length off the wall. These failures resulted in an environment which is not homelike for Resident 66 and Resident 20. Findings: During a concurrent observation and interview, on 9/8/19, at 10:37 a.m., in Resident 66 and Resident 20's room, the bottom part of the door had crusted and peeled paints. There were eight holes in the wall near the television and the bathroom sink was loose and not securely attached to the wall. Resident 66 stated, The door had crusted and peeled paints since I got here. The sink is coming off…

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 send a copy of the resident's transfer or discharge notification to the state long term care Ombudsman office for two of seven sampled residents (Resident 445 and Resident 2) when Resident 445 and Resident 2 were transferred to the General Acute Care Hospital (GACH). These failures resulted in the long term care Ombudsman not being aware of Resident 445 and Resident 2's transfer and discharge circumstances should appeals be filed by the residents or their representative. Findings: During a concurrent interview and record review with the Social Services Director (SSD), and the Administrator (ADM), on 9/10/19, at 8:18 a.m., the SSD reviewed Resident 445's clinical record dated 5/26/19, which indicated Resident 445 fell and was transferred to GACH. The SSD stated she did not send a copy of the transfer and discharge notification to the state long term care Ombudsman. The SSD stated she was not aware she needed to notify the ombudsman when a resident was transferred to the GACH. The SSD stated Resident 445 was transferred 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 interview and record review, the facility failed to complete a quarterly Minimum Data Set (MDS) assessment (an evaluation of a resident's cognitive and functional status) every 3 months for one of two sampled residents (Resident 29). This failure had the potential to delay the review and revision of the ongoing comprehensive care plan necessary to provide individualized care and services to Resident 29. Findings: During a concurrent interview and record review with the Minimum Data Set Coordinator (MDSC) 2, on 9/9/19, at 8.20 a.m., Resident 29's MDS most current assessment was dated 5/25/19. MDSC 2 stated Resident 29's quarterly MDS assessment dated [DATE] was the last MDS completed for Resident 29. MDSC 2 stated Resident 29's quarterly MDS assessment should have been completed every three months. MDCS 2 stated the quarterly MDS for Resident 29 was overdue and should have been completed by 9/8/19. Review of professional reference from the Centers for Medicare and Medicaid Services (CMS's) RAI [Resident…

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

Based on interview and record review, the facility failed to meet the required timelines for encoding, completion and transmission of Minimum Data Set (MDS) assessments (evaluation of cognition, care needs and functional abilities) for six of six sampled residents (Resident 66, Resident 17, Resident 15, Resident 12, Resident 18 and Resident 79). This practice resulted in not placing the most up to date MDS assessment information in the residents' clinical record and not communicating to CMS required quality data. Findings: During an interview with the MDS Coordinator, on 9/9/19, at 9 a.m., she stated there were some MDS assessments that were not transmitted into the MDS software. The MDS Coordinator stated the previous MDS Coordinator did not complete the MDS assessments for the facility residents. The MDS Coordinator stated the facility did not have the most recent MDS assessment inside the residents' clinical record. During an interview with the Administrator (ADM), on 9/9/19, at 9:15 a.m., he stated he was aware the MDS submission was late but he was not aware of how late the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 92) baseline care plans were developed within 48 hours of admission to facility when: Resident 92's use of hypnotic medication (medication used to sleep) was care planed eight days following admission to facility. This failure placed Resident 92 at risk to experience difficulty with sleep during the initial nights following his admission to the facility. Findings: During a review of Resident 92's face sheet (document with personal identifiable information) dated 9/8/19, indicated Resident 92 was admitted to the facility on [DATE]. Resident 92's diagnosis included of Bipolar Disorder (mental illness that causes dramatic shifts in a person's mood, energy and ability to think clearly). During a concurrent interview and record review with the Minimum Data Set Coordinator (MDS) 2, on 9/10/19 at 3 p.m., Resident 92 physician orders dated 9/8/19, indicated, Temazepam Capsule 7.5 milligram [mg] .for inability to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide toenail and foot care for one of three sampled residents (Resident 20), when Resident 20's toenails were untrimmed and curled over her ten toes. This failure resulted in Resident 20's care needs going unmet and placed Resident 20 at risk for developing injury and or infections to her feet. Findings: During a concurrent observation and interview with Resident 20, on 9/8/19, at 10:50 a.m., Resident 20's toenails on both feet were long, untrimmed, curled over the toes and was approximately 1.5 centimeters (cm- a unit of measurement) in length. Resident 20 stated she staff had not trimmed her toenails for several months. Resident 20 stated she could not reach her toenails and trim them herself. Resident 20 stated she could not understand why staff could not help her cut her toe nails. Resident 20 stated she did not like to have long toenails. During a concurrent observation and interview with Certified Nursing Assistant (CNA) 3, on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents receive services to maintain vision for one of one sampled resident (Resident 14) when: The Social Service Director (SSD) did follow up with recommendation for Resident 14 to be seen by an ophthalmologist (specialist in the treatment of disorders and diseases of the eye) referral. This practice resulted in Resident 14's visual needs to go unmet and a potential to affect Resident quality of life. Findings: During a concurrent observation and interview with Resident 14, on 9/8/19, at 11:23 a.m., Resident 14 pointed to his right eye and stated, I have a bad right eye and it has gotten worse now. Resident 14 stated he did not use eyeglasses. During a review of Resident MDS assessment dated [DATE], indicated, Resident 14's vision was Adequate and did not use eye glasses. During a concurrent interview and record review of Resident 14's clinical record with the Social Service Director (SSD), on 9/11/19, at 11 a.m., Resident 14…

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

Based on interview and record review, the facility failed to provide sufficient staff with the appropriate competencies and skill sets to provide nursing services to assure residents receive services to maintain their highest practicable physical, mental, and psychosocial well-being when: 1. Three of five nursing staff (Licensed Vocational Nurse [LVN 2], LVN 3 and the Registered Nurse [RN]) did not receive a competency skills check after being hired. 2. LVN 4 did not receive competency training on the completion of Dialysis [a process that removes waste products from the blood when the kidneys do not function] Communication document. These failures had the potential for the needs of the elderly and dementia residents going unmet. Findings 1. During a concurrent interview and record review with the DSD, on 9/10/19, at 2:18 p.m, she reviewed LVN 2, LVN 3, and RN employee record. The DSD stated LVN 2 did not receive a competency skills check after being hired for medication administration. The DSD stated LVN 3 did not receive a medication competency skills check after being hired. The…

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

Based on observation, interview, and record review, the facility failed to ensure food met the nutritional needs of the residents taking into consideration the resident's preferences when: 1. Resident 49 was not served 4 ounces (oz) of juice according to the resident's meal ticket. 2. Resident 24 was not served 4 oz of juice according to the resident's meal ticket . These failures had the potential to result in residents not receiving their dietary needs when the residents' beverage preferences were not provided which can further compromise their medical status. Findings: 1. Resident 49's meal ticket dated 9/8/19 indicated,8 oz NT (Nectar Thick) Fortified Milk, 4 oz (ounces) NT Juice. During a lunch observation in the assisted dining room on 9/8/19, at 11:53 a.m. Resident 49 was served his lunch tray. Resident 49's lunch tray included an 8 oz thickened milk and an 8 oz of thickened water in nosey cups. There was no thickened 4 oz juice served to Resident 49. During a concurrent interview with the Registered Nurse (RN) 2 and the Restorative Nurse Assistant (RNA) 2 both validated…

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

Based on observation, interview and record review, the facility failed to ensure the chemical sanitizing solution used for dishes, utensils and kitchen working surfaces met the recommended sanitation concentration when expired chemical test strips were used. This practice failed to ensure the required level of sanitation was followed and placed the residents and staff of the facility at risk for food borne illness. Findings: During a concurrent observation and interview with Dietary Aide (DA) 1, on 9/8/19, at 8:56 a.m., DA 1 took a test strip to test the sanitizing solution in a red bucket. DA 1 stated the solution in the red bucket was used to sanitize the countertops of the kitchen. The Quaternary Sanitizer (a form of disinfectant) (QT) test strip used by DA 1 indicated an expiration date of 11/30/18. DA 1 stated the test strips were expired and should not have been used. DA 1 stated he did not know the test strips had an expiration date. DA 1 stated the expiration date should be checked prior to using. During an interview with the Certified Dietary Manager (CDM), on 9/8/19, at…

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

Based on observation, interview, and record review, the facility failed to provide two of two sampled residents (Resident 24 and 49) beverages appropriate to meet the residents' needs when: 1. Resident 49 was served a glass of water not thickened according to the physician's orders. 2. Resident 24 was not served glass of water not thickened according to the physician's orders. These failures placed Residents 24 and 49 at risk of choking (liquid that could be caught in the throat blocking airway and making it difficult or impossible to breathe). Findings: 1. Resident 49's physician's order dated 9/8/19 indicated, Dietary- Diet- . Pureed texture, Nectar Thick Liquids consistency . NOSEY CUP. Resident 49's meal ticket dated 9/8/19 indicated,8 ounces (oz) NT (Nectar Thick) Fortified Milk, 4 oz NT Juice. During a lunch observation in the Assisted Dining room on 9/8/19, at 11:53 a.m. Resident 49 was served his lunch tray. Resident 49's milk and water were in nosey cups. Certified Nurse Assistant (CNA) 10 showed Restorative Nurse Assistant (RNA) 2 Resident 49's water not thickened to 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 maintain an accurate medical record consistent with professional standards and practices for two of seven sampled residents (Resident 66 and Resident 29) when: 1. Resident 66's comprehensive care plan on anticoagulant therapy did not address the anticoagulant medication she was prescribed. 2. Resident 29's Dialysis (process of removing waste from the kidney artificially)Communication document did not contain Pre-dialysis assessments. These failures resulted in a medical records that did not reflect the resident's condition and treatments of the care and services required by the resident's and their care needs. Findings: 1. During a concurrent interview and record review with the Minimum Data Set (MDS- assessment of healthcare and functional needs) Coordinator on 9/9/19, at 9 a.m., she reviewed Resident 66's clinical record and stated Resident 66 was on Apixaban (anticoagulant medication to prevent blood clots from sticking). The MDS Coordinator reviewed Resident 66's care plan dated 7/27/19 which indicated, . [Resident 66]…

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 maintain an effective infection control program when: 1. Tuberculosis (TB) (a contagious infection of the lungs) skin test was not provided on an annual basis for three of three sampled residents (Resident 20, Resident 4, Resident 3). 2. Staff did not perform hand hygiene during the lunch observation conducted on 9/8/19 for 2 residents in the assisted dining room (Resident 49 and Resident 24) when: a. Restorative Nursing Assistant (RNA) 2 and Certified Nurse Assistant (CNA) 10 failed to provide Resident 49 and Resident 24 wet hand towels to clean the residents' hands before meals. b. CNA 10 did not wash or sanitize hands before meal set up for Resident 49 and before providing feeding assistance to Resident 24. c. RNA 2 did not wash or sanitize hands before providing feeding assistance to Resident 49. These failures placed the resident's health and safety at risk for contraction and spread of unidentified Tuberculosis to other residents and the potential harbor of organisms (germs)and spread of infection. Findings: 1.…

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

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 39) were treated with respect and dignity when: Certified Nusing Assistant (CNA 2) did not provide Resident 39 with adequate incontinent care and left Resident 39 with dry smeared stool in her perineal (peri) area (diamond-shaped area that includes the anus and, in females, the vagina). This failure resulted in Resident 39 feeling embarrassed and humiliated. Findings: During an interview with Resident 39, on 8/23/19, at 11:35 a.m., Resident 39 stated she was not provided with adequate incontinent care on 8/7/19 and was left with dry stool on her peri- area. Resident 39 stated a CNA found the dry smear of bowel movement in her peri-area the following day. Resident 39 stated, I did not like the feeling of being left dirty. [It] did not feel good [to have dry smeared bowel movement (BM) on me]. It made me feel dirty. I felt so embarrassed and humiliated. I was so ashamed there was [BM] in my private area. During a review of Resident 39's clinical record, the facility document…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to accurately reflect the status for one of three sampled residents (Resident 14) when Resident 14's vision impairment was not accurately coded on the Minimum Data Set (MDS) assessment (evaluation of care and functional needs). This failure resulted in an inaccurate vision assessment for Resident 14 which placed Resident 14's vision needs unmet. Findings: During a concurrent observation and interview with Resident 14, on 9/8/19, at 11:23 a.m., Resident 14 pointed to his right eye and stated, I have a bad right eye and it has gotten worse now. Resident 14 stated he did not use eyeglasses. During a review of Resident MDS assessment dated [DATE], indicated, Resident 14's vision was Adequate and did not use eye glasses. During a concurrent interview and record review of Resident 14's clinical record with the Social Service Director (SSD), on 9/11/19, at 11 a.m., Resident 14 was seen by an eye provider on 3/7/19 with a recommendation for new…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 28) receive the necessary services when staff did not provide a urinal for Resident 28's use after he requested. This failure resulted in Resident 28's urine incontinent spells on the night shift of 9/6/19 and 9/8/19. Findings: During a concurrent observation and interview with Resident 28 on 9/8/19, at 9:10 a.m. in his room, Resident 28 stated he had bad knees and he could not get out of bed and walk to the bathroom. Resident 28 stated he requested a urinal several times to multiple staff. Resident 28 stated he wanted the urinal for use during the night time. During a review of Resident 28's Minimum Data Set (MDS- assessment of cognitive status and functional needs) assessment dated [DATE], indicated Resident 28 had no memory impairment with a Brief Interview for Mental Status (BIMS- assessment for cognitive status) score of 15 out of 15 points. Resident 28's MDS Bladder and Bowel section H…

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 care and services in accordance with the facility policy and procedures for one of 33 sampled residents (Resident 63) when: the interdisciplinary team (IDT- members of the care team made up of nurses, social workers, doctors, dieticians and other appointed staff) did not implement or revise interventions to prevent Resident 63's significant weight loss. The Certified Dietary Manager (CDM) and the nursing staff failed to accurately document and monitor the consumption of nutritional supplements ordered for Resident 63 unintended weight loss. This practice potentially compromised Resident 63's nutritional status by failing to establish meaningful interventions that addressed Resident 63 nutritional risks and resulted in his 49 pound (lbs.-unit of measurement) unintended weight loss over a period of three months and placed him at risk for decline in overall health. Findings: During an observation and interview in Resident 63's room…

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 psychotropic medication (used to affect the mind, emotions, and behavior) for one of one sampled resident's (Resident 68) was not administered beyond a fourteen day period when ordered on a PRN (Whenever needed) basis without a documented rationale by the physician. This failure placed Resident 68's health and safety at risk due to the continuous administration of the unnecessary psychotropic medications. Findings: During a review of the clinical record for Resident 68, the admission Record (document with resident demographic information) dated 2/21/19 indicated Resident 68 was readmitted to the facility on [DATE]. Resident 68 was admitted with a medical diagnosis which included Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), recurrent and unspecified. A review of Resident 68's physician's order dated 9/8/19 indicated a medication order dated 7/22/19 for Temazepam capsule 7.5…

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 timely dental services to one of one sampled resident's (Resident 36) when the Social Service Director (SSD) did not follow up Resident 36's dental recommendation. This failure resulted in the delayed meeting of the ongoing dental needs of Resident 36. Findings: During a review of the clinical record for Resident 36, the admission Record (document with resident demographic information) indicated Resident 36 was admitted to the facility on [DATE]. Resident 36's Minimum Data Set (MDS-a required assessment of physical and cognitive abilities) dated 6/4/18, indicated Resident 28's Brief Interview for Mental Status (BIMS- assessment for cognitive status) score was 15 of 15 points which indicated Resident 28 was cognitively intact. The MDS Section L (Oral/Dental Status) indicated, No natural teeth or tooth fragments . During a concurrent observation and interview with Resident 36 in his room, Resident 36 had his upper and lower teeth…

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 safely store food in accordance with professional standards for food service safety when an opened rectangle block of butter was not dated. This failure to ensure safety in food service placed the residents at risk for food borne illness and the growth of microorganisms. Findings: During a concurrent observation and interview with [NAME] 1 on 9/8/19 at 9 a.m., [NAME] 1 opened the freezer and found a rectangle block of butter that was opened and undated. [NAME] 1 stated all items in the kitchen that were opened needed to be dated. During an interview with the Certified Dietary Manager (CDM), on 9/8/19, at 2:22 p.m., he stated all food items in the kitchen that were opened needs to be dated and the butter should have been when first opened. The facility policy and procedure titled, Labeling and Dating of Foods dated 2018, indicated, Policy: All food items in the . refrigerator, and freezer need to be labeled and dated .