Community Care And Rehabilitation Center

Based on observation, interview, and record review, the facility failed to follow the physician's prescribed diet order when: 1. Heart Healthy diet was given the food item that was not consistent with the [NAME] Spreadsheet; and 2. Renal and Liberal House Renal diets were given the food item that was not consistent with the [NAME] Spreadsheet on 5/525 and 5/6/25. These failures had the potential to negatively impact the residents' nutritional status and further compromising resident's medical status. Findings: 1. A review of the facility [NAME] Spreadsheet (the document used to guide dietary staff on food items, portions, and therapeutic diet) dated on May 5, 2025, indicated, Heart Healthy diet served seasoned Pasta. On May 5, 2025, at 12:10 p.m., during trayline (a system of food preparation in which trays move along an assembly line) observation in the kitchen. Checking each food items were going to serve at the steamtable. There was no pasta available at the steamtable. On May 5, 2025, at 12:56 p.m., an observation was conducted with Resident 66 in the dining room. Resident 66'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 maintain a sanitary environment, prepare, and served food in accordance with professional standards for food service safety when: 1. Raw meats were holding for extended periods of time for thawing; 2. Multiple pieces of equipment that were not clean to sight and/or touch found in kitchen; 3. Multiple areas and pieces of equipment covered with dust were found in kitchen; 4. Storage shelves at dry storage did not have smooth surface; 5. Screened door at dry storage had gap; 6. Two non-dietary staff entered the kitchen without hairnets; 7. Personnel belongings found at dry storage; 8. Dry storage shared with dietary staff break room; and 9. Expired foods found at resident's refrigerator. These failures had the potential to result in cross contamination (bacteria are unintentionally transferred from one substance or object to another with harmful effect) and foodborne illnesses (are illnesses that results from ingesting contaminated foods) for 136 of 136 sampled residents who received foods from the kitchen.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 of garbage and refuse properly when trash were found outside on the floor surrounding the dumpsters. In addition, the lids of the dumpsters did not close properly. This failure had the potential to attract pests. Findings: On May 5, 2025, at 8:34 a.m., an observation was conducted outside the facility at the overflow parking lot. A green waste dumpster was observed widely open with some tree branches, and cardboard inside the dumpster. A pair of used blue glove, empty beverage cans, papers outside surrounding the dumpster. On May 5, 2025, at 2:11 p.m., and 4:43 p.m., an observation was conducted outside the facility at the overflow parking lot. The green waste dumpster was observed still widely open with green waste, and cardboard inside. And some trash surrounding the dumpster. On May 6, 2025, at 8:23 a.m., an observation was conducted outside the facility at the overflow parking lot. The green waste dumpster was observed still widely open with green waste, and cardboard inside. And some trash…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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. On May 5, 2025, at 1:57 p.m., an observation and concurrent interview was conducted with Resident 183. Resident 183 was lying in bed, awake, alert, and able to verbalize his needs. An oxygen concentrator (a device that extracts oxygen from the air and delivers a concentrated oxygen to the patient) was observed at the bedside, with oxygen nasal cannula tubing (a thin flexible tube with two prongs that delivers oxygen through the nose) connected to the concentrator. The nasal cannula tubing was observed inside the upper drawer of the resident's nightstand. Resident 183 stated he had not used his oxygen for two weeks. He stated he felt fine without the oxygen. On May 6, 2025, at 2:03 p.m., an interview was conducted with Certified Nursing Assistant (CNA) 4. CNA 4 stated Resident 183 only used his oxygen as needed. She stated he went to the therapy today and was not sure if he had used his oxygen. CNA 4 acknowledged the oxygen nasal cannula tubing was coiled inside the top drawer of the nightstand. She stated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the call light system (a communication system that allow the resident to call for staff assistance) located in Station 2 had an adequate audible sound. This failure had the potential for the residents located in Station 2 not to receive assistance from the staff in a timely manner. Findings: On May 6, 2025, the Resident Council (a group of residents in the facility that meets regularly to address issues and concerns to improve resident satisfaction) meeting minutes for February 2025, March 2025, and April 2025, were reviewed. The minutes for March and April 2025, indicated the call lights were not answered in a timely manner. On March 6, 2025, at 2:03 p.m., the Resident Council meeting was conducted with six residents present. During the Resident Council meeting, the call-light response time for the evening shift in Station 2 was still a concern. Resident 73 stated he would get out of bed, walk to the door and yell out for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure three (3) of five (5) residents reviewed (Residents 4, 10, 182) were free from unnecessary psychotropic (drugs that affects brain activities associated with mental processes and behavior) medications including venlafaxine (an antidepressant medication used for depression [mental health condition characterized by persistent feelings of sadness] , anxiety [human emotion charaterized by feelings of unease, worry, or fear], and panic disorder [brief episode of intense anxiety, which causes the physical sensation of fear]) and Seroquel (an antipsychotic medication for bipolar disorder [disorder associated with episodes of mood swings ranging for depressive lows to manic highs], depression, and schizophrenia [chronic brain disorderthat affects thinking, feeling, and behavior]) when: 1. Residents 10 and 182 were administered venlafaxine without potential adverse effect monitoring documented during use of venlafaxine; and 2. Resident 4 was administered…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an allegation of abuse involving one of three residents reviewed (Resident 55) to California Department of Public Health (CDPH) immediately, but not later than 2 hours after the allegation was made. The facility staff was made aware on April 13, 2025. This failure resulted in the delay of abuse investigation, that placed Resident 55 and other residents at risk when the Certified Occupational Therapy Assistant (COTA) was not suspended immediately in accordance with the facility's policy and procedure. Findings: On May 5, 2025, a review of Resident 55's record indicated Resident 55 was admitted to the facility on [DATE], with diagnoses which included dysphagia (difficulty in swallowing)following cerebral infarction (also known as ishemic stroke, when the blood flow to the brain is blocked, causing the brain tissue to die), and aphasia (a disorder that affects the ability to speak and understand what others say). A review of the Minimum Data Set…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the comprehensive care plans were developed and implemented when: 1. For Resident 10, the care plan for the use of Effexor (brand name for venlafaxine, an antidepressant medication used for depression, anxiety, and panic disorder) XR (extended release, designed to release medicine slowly into the body over a prolonged period) was not initiated and developed. This failure had the potential to increase Resident 10's risk of not being provided appropriate, consistent, and individualized care. 2. For Resident 11, the care plan for the right leg edema was not initiated and developed. This failure had the potential not to be able to meet the person-centered goals and objectives for Resident 11's right leg edema and delay the necessary care and services for her recovery and discharge. Findings: 1. A review of Resident 10's admission record indicated he was admitted to the facility on [DATE], with diagnoses which included depression. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure safe smoking practices were observed and implemented for two of 12 residents reviewed for smoking, when: 1. Resident 29's cigarettes were not stored in the lock box provided by the facility; and 2. Resident 84's smoking materials (cigarettes and lighter) were not stored in the lock box provided by the facility. These failures had the potential to result in accidents or injuries to the facility residents. Findings: 1. On May 7, 2025, at 12:57 p.m., an observation was conducted with Resident 29. Resident 29 was observed in his room, sleeping in his bed. A pack of cigarettes was observed on Resident 29's nightstand open shelf, readily available. On March 7, 2025, at 1:05 p.m., an interview was conducted with the Activities Director (AD). The AD stated a Smoking Safety assessment is done for each resident upon admission and reviewed with nursing. The AD stated the decision whether a certain resident can smoke unsupervised or supervised…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities during the monthly medication regimen review (MRR) when Resident 4 received Seroquel (an antipsychotic medication for bipolar disorder, depression, and schizophrenia) without manufacturer specified monitoring. This failure had the potential for medications not being optimized for best possible health outcome, and increased risk for adverse effects for the residents. Finding: A review of Resident 4's admission record indicated she was initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses which included schizoaffective disorder (mental health condition characterized by psychotic symptoms like hallucinations/delusions and mood episodes like mania or depression). A review of Resident 4's medical record indicated she had been receiving Seroquel in various doses since February 2022. A review of Resident 4's current Order Summary Report, dated May 9,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the lubricant eye drops solution was safely stored for one of 28 residents reviewed (Resident 186). This failure resulted in Resident 186 administering the eye drops solution without physician's order, self-administration assessement, and supervision. In addition, this placed Resident 186 at risk for unsafe medication administration and has the potential to alter the efficacy of the eye drops solution being stored at resident's bedside. Findings: On May 6, 2025, at 3: 11 p.m., Resident 186 was observed lying in bed awake, alert, oriented and able to verbalize her needs. One eye drops lubricant solution was observed on top of her overbed table. She stated her family member brought the eye drops from home. She stated she had used the eye drops for years as needed for her left eye. The eye drops lubricant solution was labeled .equate Dry Eye Relief, Lubricant Eye Drops Soothing Relief for dryness and irritation 0.5 FL OZ (Fluid Ounces…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the Dietary Supervisor (DSS - the position responsible for the day-to-day operation of the dietary department), met the educational requirements as outlined in the Federal Regulation, and California Health and Safety Code. Findings: According to California Code of Regulations, Title 22: Dietetic services are defined as the provision of safe, satisfying, and nutritionally adequate food for residents with appropriate staff, space, equipment, and supplies. Staffing requirements of dietetic services are such that if the position responsible for the day-to-day management of the department is not a registered dietitian there must be a full-time person who meets specific training requirements to be the dietetic services supervisor, responsible for the operation of the food service. According to the California, Health, and Safety Code - HSC § 1265.4: Qualifications of Dietary Supervisor: (b) The dietetic services supervisor shall have completed at least one of the following educational requirements: (1) A baccalaureate…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 for one of three residents (Resident 1), their family member was notified of Resident 1 's room change. This failure resulted in Resident 1 's Family Member, to be unaware of Resident 1's location within the facility. Findings: On March 6, 2025, at 9:26 a.m., during an interview, Resident 1 's Family Member (FM) 1 stated the facility did not notify FM 2 when they moved the resident to different rooms. On March 6, 2025, at 12:45 p.m., during a concurrent interview and observation, Resident 1 was in her current room, sitting in her wheelchair, wearing a neck brace. She was alert and conversant. Resident 1 stated she had remained in the same room since admission. A review of Resident 1's medical record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included neck fracture (a break in the bone) and need for assistance with personal care. FM 2 was the listed as the primary contact under the CONTACTS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 for one of three residents, Resident 1, that her open wound was assessed and treated after she informed a staff member about it. This failure resulted in the delay of assessment and treatment of Resident 1 's open wound and had the potential for the wound to become infected. Findings: On March 6 and 7, 2025, unannounced visits were conducted at the facility. On March 6, 2025, at 12:45 p.m., during a concurrent interview and observation in her room, Resident 1 was sitting in her wheelchair, wearing a neck brace. She was alert and conversant. Resident 1 stated she had wounds on her right lower leg and the dressing (a covering, often a bandage or pad, used to protect a wound and promote healing) had been changed earlier that day. Resident 1 also stated she bumped her left leg at the clinic where she had her CT scan (Computed Tomography scan- a medical imaging technique that reveal detailed images of the inside of the body) done either…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 practices were implemented when Certified Nurse Assistant (CNA) 2 did not wear the appropriate personal protective equipment (PPE - specialized clothing or equipment worn to create a barrier between healthcare workers and potential sources of infection, like blood, body fluids, or other potentially infectious materials) when she entered the room of a COVID-19 (a highly contagious respiratory disease) positive resident. This failure had the potential to spread COVID-19 to other residents. Findings: On March 7, 2025, at 11:22 a.m., during an observation outside Resident 2's room, there were signs by the door indicating .CONTACT PRECAUTIONS .EVERYONE MUST Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO .Put on gloves before room entry .Put on gown before room entry .DROPLET PRECAUTIONS .EVERYONE MUST .Make sure their eyes, nose and mouth are fully covered before room entry . On March 7, 2025, at 11:25 a.m., 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the call light was functioning for one of three residents, Resident 3. This failure resulted in Resident 3 waiting for a long time to be assisted with toileting hygiene. Findings: On March 7, 2025, at 10:30 a.m., during a concurrent observation and interview, Resident 3 was in her room, lying in bed, wearing a neck brace. She was alert and conversant. Resident 3 stated on the evening of March 5, 2025, she pressed on her call light because she needed to be changed and she waited for a long time, about three or four hours and she was even banging on the wall, but nobody came to her until her daughter called the facility. Resident 3 stated that when the Certified Nursing Assistant (CNA) came to change her, the CNA informed her that her call light had malfunctioned, the light bulb outside her room was not lighting up. Resident 3 stated she was not provided with an alternative method to call out for help that night. Resident 3 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 provide a notice of proposed discharge to one of three residents, Resident 2, when Resident 2 was discharged from the facility after being transferred to the general acute care hospital (GACH). In addition, the facility failed to notify the Long-Term Care (LTC) Ombudsman (an advocate for residents and families in long-term care facilities) and Resident 2's family member (FM) of Resident 2 ' s discharge from the facility. This failure placed Resident 2 at an increased risk of being discharged without having an advocate to ensure a safe and effective transition of care, or without having a clear understanding of his appeal and discharge rights. Findings: A review of Resident 2 ' s medical record was conducted on April 29, 2024. Resident 2 was admitted to the facility on [DATE], with diagnoses which included cerebral infarction (damage to tissues in the brain due to loss of oxygen to the area), hypertension (high blood pressure), depression (mood disorder…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure, for one of three residents reviewed, Resident 2, who was transferred to General Acute Care Hospital (GACH) on March 27, 2024, was re-admitted back to the facility on the first available bed. This failure resulted to a violation of Resident 2's right to be re-admitted back to the facility to the first available bed and had the potential to cause emotional distress. Findings: On April 29, 2024, Resident 2's medical record was reviewed. Resident 2 was admitted to the facility on [DATE], with diagnoses which included cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), hypertension (high blood pressure), depression (a depressed mood or loss of pleasure or interest in activities for long periods of time), schizoaffective disorder (a mental health disorder that is marked by a combination of symptoms such as hallucinations or delusions), and convulsions (condition in which muscles contract and relax quickly causing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, interviews, and facility policy review, the facility failed to ensure the Minimum Data Set assessments were accurate for 2 (Resident #9 and Resident #147) of 29 sampled residents. Specifically, the facility incorrectly coded Resident #147 being discharged to the hospital instead of home and did not accurately code Resident #9's level II preadmission screening and resident review (PASARR) status. Findings included: A review of the facility policy titled, MDS 3.0 Completion, implemented on 12/19/2022, revealed, Policy: Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan. The policy revealed, Policy Explanation and Compliance Guidelines: 1. According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident' functional capacity, using the RAI [Resident Assessment Instrument] specified by the State. 1. A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the resident's water temperatures were maintained at a comfortable level for two of five residents reviewed (Resident 2 and 5) when the resident's and/or resident ' s representatives (RR) complained the hot water took too long to heat in their bathrooms. This failure had the potential for the residents to feel uncomfortable and affect their quality of life. Findings: On February 29, 2024, at 10:30 a.m., an unannounced visit was conducted at the facility for two complaint investigations. On February 29, 2024, at 11:02 a.m., Resident 2 was observed lying in bed receiving care from the Certified Nursing Assistant (CNA). Resident 2 was non-verbal. On February 29, 2024, Resident 2 ' s record was reviewed. Resident 2 was admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses which included quadriplegia (inability to move arms and legs), contractures (shortening or hardening of muscles, often leading to deformities)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, for one of five residents reviewed (Resident 1), professional standards of practice were followed when the physician ' s order for follow up appointment was not carried out on January 26, 2024. This failure had the potential for care and services for Resident 1 to be delayed. Findings: On February 20, 2024, the department received a complaint indicating Resident 1 had a follow up appointment with her spinal surgeon. The complainant indicated the day of Resident 1 ' s scheduled appointment she received notice that Resident 1 could not attend her appointment due to issues with transportation. On February 29, 2024, at 10:30 a.m., an unannounced visit was conducted at the facility for two complaints. On February 29, 2024, Resident 1 ' s record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included fracture of the first cervical vertebrae (bones in the neck/spine), fracture of the thoracic vertebrae (bones in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement interventions which had the potential to result in, and/or contribute to, the worsening of a pressure injury/ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) for one of five residents (Resident 1), when Resident 1 was admitted to the facility with a pressure ulcer/injury on the coccyx (base of the spine) and there were no documented skin assessments after admission. This failure had the potential to place the resident at an increased risk for pain and infection. Findings: On February 29, 2024, at 10:30 a.m., an unannounced visit was conducted at the facility for two complaints. On February 29, 2024, Resident 1 ' s record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included fracture of the first cervical vertebrae (bones in the neck/spine), fracture of the thoracic vertebrae (bones in the chest area of the spine), and history of falls. Review of Resident 1 ' s…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an allegation of verbal abuse involving a resident (Resident 1) and a Licensed Vocational Nurse (LVN 1) to the State Survey Agency immediately, but not later than two hours after the allegation was made. This failure had the potential to result in further abuse and harm for the resident involved. Findings: The California Department of Public Health (CDPH) received an allegation of abuse from the facility on November 8, 2023, at 4:30 p.m., when the facility reported it to CDPH. The allegation of abuse took place at the facility on November 5, 2023, at approximately 10:30 a.m. On November 15, 2023, at 9:40 a.m., during an interview with LVN 1, LVN 1 denied the abuse allegation involving Resident 1. LVN 1 stated she was not aware of the abuse allegation brought forth by CNA 1 on November 8, 2023. LVN 1 stated staff at the facility must report right away any abuse allegation to the abuse coordinator, which is the Administrator (ADM). On November 15,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 notify one (Resident 1) of three sampled residents Responsible Person (RP; person designated as being responsible for another person's medical and financial decisions) of a change in condition and had to be admitted to the acute care hospital setting. This failure resulted in violation of Resident 1's rights. Findings: On September 08, 2023, at 4:05 p.m., the Department received a complaint, indicating Resident 1 was missing from the facility for over three days and facility did not inform the responsible person of Resident 1's transfer to acute care hospital. On September 14, 2023, at 8:48 a.m., an unannounced complaint investigation was conducted at the facility. Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with a diagnosis that included a surgical aftercare following surgery of the circulatory system. Resident 1's profile indicated Resident 1 has emergency contact persons listed. Order dated September 31,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident's safety and provide adequate supervision specific to residents with cognitive impairment, wandering behavior, and risk for elopement (leaving a facility without notice) for one of three residents reviewed (Resident 1). In addition, the facility failed to implement safety measures to secure the main entrance door where Resident 1 exited the facility. This failure resulted in Resident 1's elopement and increased the potential to expose Resident 1 to harm, accidents, injury and illnesses. Findings: On June 1, 2023, an unannounced visit to the facility was conducted to investigate one Facility Reported Incident. During a review of Resident 1's record on June 1, 2023, the record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included Alzheimer's disease (a progressive disease that destroys memory and other mental functions). Resident 1's history and physical dated December 9, 2022,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 necessary dental services for one of four residents reviewed, (Resident 2), when there was no follow up dental services to address Resident 2's full set of new dentures. This failure had the potential for Resident 2 to have increased pain due to poor fitting dentures. Findings: On June 19, 2023, at 12:14 p.m., an unannounced visit to the facility was initiated for a complaint investigation. A review of Resident 2's medical records indicated he was admitted on [DATE], and discharged on February 1, 2022, with diagnoses of benign prostatic hyperplasia, (BPH - enlargement of the prostate gland caused by a benign overgrowth of chiefly glandular tissue that occurs especially in some men over [AGE] years old and that tends to obstruct urination by constricting the urethra), hypothyroidism, (a condition resulting from decreased production of thyroid hormones), diabetes mellitus type 2, (a chronic condition that affects the way the body uses sugar. 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 safety requirements for food storage and preparation were followed when: 1(a) Multiple food items stored in the dry storage area were not labeled with the name of the food item, the opened date, or use-by date; 1(b) Multiple food items stored in the refrigerator were not labeled with opened dates or use-by dates; 2. The kitchen ice machine had a yellowish-brown slimy substance located on the inside cover; and 3. The kitchen manual can opener had an accumulation of a dry reddish brown stain on and around the blade and on the base of the can opener. These failures had the potential to place the residents of the facility at risk for food-borne illness in a medically vulnerable resident population who consumed food in the facility. The facility census was 125. Findings: 1(a) On June 7, 2021, beginning at 8:48 a.m., during the initial kitchen tour with the Dietary [NAME] the following were observed in the dry storage room: - five corn flakes in a styrofoam cup - with no name of the food item and was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure there was documented evidence Advance Directive (written instruction related to the provision of health care when the resident is no longer able to make decisions) information was provided to the resident and/or responsible party (RP), for four of 22 residents reviewed (Resident 32, 75, 80, and 114). This failure had the potential for Residents 32, 75, 80, and 114, not to be able to exercise their rights to formulate an Advance Directive. Findings: 1. On June 7, 2021, Resident 32's record was reviewed. Resident 32 was admitted to the facility on [DATE]. The record indicated a family member was Resident 32's responsible party (RP). The physician history and physical dated December 30, 2020, indicated Resident 32 did not have the capacity to understand and make decisions. The Social Service notes dated March 17, 2021, were reviewed. There was no documented evidence the facility provided information to Resident 32's RP regarding the right to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure four of 32 residents reviewed for care and treatment (Residents 63, 75, 100, and 379) maintained their highest practicable physical well-being when the facility did not identify and assess a dark bluish skin discoloration (bruises) for Residents 63, 75, 100, and 379 in a timely manner. This failure had the potential for Residents 63, 75, 100, and 379, to not receive care and treatment for the skin discolorations and may result in a delay in the investigation to determine the cause of the skin discolorations. Findings: 1. On June 7, 2021, at 11:54 a.m., Resident 63 was observed sitting in the wheelchair, alert and conversant. Multiple dark bluish and fading skin discolorations on the resident's upper extremities were noted. On the right upper extremity there were 10 sites, and on the left upper extremity there were five sites observed. On June 10, 2021, at 10:36 a.m., the Director of Nursing (DON) was interviewed. The DON was asked…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 for three sampled residents (Resident 42, 24, and 115) to ensure: 1. For Resident 42, a pain assessment was conducted and non-pharmacological interventions were provided by the licensed nurse prior to administering the PRN (medication taken only as needed) Percocet (a narcotic pain medication) on June 5, 6, 7, and 8, 2021; 2. For Resident 24, a pain assessment was conducted and non-pharmacological interventions were provided by the licensed nurse prior to administering the PRN Norco (a narcotic pain medication) on June 9, 2021; and 3. For Resident 117, a pain assessment was conducted and non-pharmacological interventions were provided by the licensed nurse prior to administering the PRN Norco on May 17, 18, and 30, 2021. These failures had the potential to increase usage of pain medications which could lead to drug tolerance (reduced reaction to a drug following repeated use) resulting in ineffective pain management and diminished quality of life.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 control precautions to prevent cross contamination and maintain a sanitary environment when: 1. Two Treatment Nurses were observed providing wound care to Resident 7 after the lunch meal tray was served; 2. Two staff were observed to have artificial fingernails when assisting a resident while eating and when checking the resident's meal tray; and 3. One Licensed Nurse was observed wearing gel nail polish and nail enhancements during a medication administration observation. These failures increased the risk of cross-contamination which could result in the development and transmission of infections to a vulnerable population of 125 residents. Findings: 1. On June 7, 2021, during the lunch meal observation. The following was observed: - At 12:46 p.m., Resident 7's lunch meal tray was served in his room. - At 12:48 p.m., a treatment cart (cart containing wound care supplies) was observed in front of Resident 7'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 observation, interview, and record review, the facility failed to provide meal service in a dignified manner for one of 10 residents (Resident 66) observed during lunch when the facility did not serve the resident's lunch at the same time as her roommate (Resident 36) while both residents were inside the room. This failure resulted in Resident 66 watching her roommate eat before she was served, which had the potential to cause feelings of decreased self worth. Findings: On June 7, 2021, at 12:20 p.m., the lunch meal service was observed in the hallway. The lunch meal cart arrived at Nurse's Station 2 and two licensed nurses checked the meal trays. On June 7, 2021, at 12:23 p.m., Resident 36 was wheeled inside room [ROOM NUMBER], and served the lunch meal. Resident 66 was observed in bed in an upright position, awake, staring at Resident 36 while she was eating. Resident 66 did not receive her meal at the same time as Resident 36. On June 7, 2021, at 12:25 p.m., Licensed Vocational Nurse (LVN) 1 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the resident was safe to self-administer medications, for one resident (Resident 60) reviewed for self-administration of medications. This failure had the potential for Resident 60 to self-administer medications unsafely. Findings: On June 8, 2021, at 2:51 p.m., Resident 60 was observed lying in bed, alert, and conversant. One bottle of Eye Relief (eye drop medication to treat dry eyes) was observed on top of Resident 60's bedside drawer. During a concurrent interview, Resident 60 stated she used eye drop medication when her eyes were dry. Resident 60 stated the nurses were aware she had the eye drop medication at her bedside. On June 8, 2021, Resident 60's record was reviewed. Resident 60 was admitted to the facility on [DATE]. The recapitulated physician order for May 2021, was reviewed. There was no physician order for the eye drop medication and no order to self-administer medication for Resident 60. On June 9, 2021, at 1:32…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, for one of eight sampled residents (Resident 8), the professional standard of practice was followed when there was missing documentation to indicate nasal iodophor 10% antiseptic (a substance that stops or slows down the growth of microorganisms) was administered as ordered. This failure resulted in inaccurate documentation of Resident 8's care potentially resulting in unnecessary changes to Resident 8's plan of care. Findings: On June 10, 2021, Resident 8's record was reviewed. Resident 8 was admitted to the facility on [DATE]. The physician's order dated May 27, 2020, indicated, .Apply nasal iodophor 10% antiseptic single swab to each nostril routine cycle . unless allergic, every day and evening shift every two weeks on Mon, Tue, Wed, Thu, Fri for prophylaxis (measures designed to preserve health and prevent the spread of disease) . The Treatment Administration Record (TAR) for March and April 2021, indicated to administer the nasal swab 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 one of three residents (Resident 328) reviewed for ADL (Activities of Daily Living) was provided with nail care. This failure resulted in Resident 328 to not receive services for proper grooming and personal hygiene. Findings: Resident 328 was observed with long fingernails, approximately 0.4 centimeter (cm - a unit of measurement) beyond the fingertips, with yellowish brown matter underneath all fingernails on the following dates and times: - June 7, 2021, at 12:29 p.m.; - June 8, 2021, at 9:01 a.m.; - June 9, 2021, at 2:21 p.m.; and - June 10, 2021, at 8:14 a.m. On June 10, 2021, at 9:46 a.m., a concurrent observation and interview was conducted with Certified Nurse Assistant (CNA) 1. CNA 1 stated yes, her fingernails are long and need to be trimmed. CNA 1 stated Resident 328 was assigned to her care yesterday (June 9, 2021). CNA 1 stated she did not perform fingernail care yesterday. On June 10, 2021, at 9:48 a.m., 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow their policy and procedure on safe smoking practices for three of 19 residents (Residents 1, 51 and 115) reviewed for smoking when: 1. Resident 1's smoking materials were not kept in a locked box. 2. Resident 51 smoked in his own patio and not in the designated smoking area; Further, he used oxygen at night and as needed during the day; and 3. Resident 151 did not have a smoking apron on while smoking, and was unsupervised by facility staff while smoking. These failures had the potential to increase the residents' risks for smoking related injuries and accidental fires. Findings: 1. On June 8, 2021, at 12:30 p.m., a concurrent observation with interview was conducted with Resident 1. Resident 1 stated, he smoked, and he kept his lighter and cigarettes with him. On June 8, 2021, at 12:35 p.m., an observation was conducted in Resident's 1's room. A No Smoking Oxygen in Use, sign was noted on the entry doorway. Resident 1's roommate…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that the menu was being followed for the therapeutic diet on June 7, 2021, during lunch meal observation when: 1. Resident 16, who was on a double portion regular texture NAS (no added salt) diet did not receive an orange or melon slice as indicated on the menu; and 2. Resident 36 who was on a regular puree (regular diet modifies in texture of a smooth and moist consistency and able to hold its shape. Foods usually in soft and smooth state such as pudding or mashed potatoes) diet did not receive egg noodles and parsley flakes as indicated on the menu. These failures had the potential to result in compromising the medical and nutritional status of Residents 16 and 36. Findings: 1. During the lunch meal observation on June 7, 2021, beginning at 12:37 p.m., Resident 16's meal tray was served to him in his room. Observed on his meal tray were the following: - two rolls of bread, one cup of coffee; - two cream packets; - two packets 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 observation, interview, and record review, the facility failed to serve food to meet the individual needs for one of three sampled residents (Resident 380) reviewed for nutrition, when Resident 380 was served a puree (regular diet modified in texture to a smooth and moist consistency and able to hold its shape. Foods usually in a soft and smooth state such a spudding or mashed potato) diet for breakfast, lunch and dinner on June 9, 2021, inconsistent with the physician's diet order. The facility failure had the potential to negatively affect Resident 380's intake which could result in compromised nutritional status. Findings: On June 8, 2021, at 3:32 p.m., a concurrent observation and interview was conducted with Resident 380. Resident 380 was observed lying in bed, awake. Resident 380 stated the Speech Therapist advanced his diet to a regular diet from a pureed diet on June 7, 2021. Resident 380 stated he received a pureed diet for breakfast and lunch on June 8, 2021. Resident 380 stated he 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.